Current Status of Robotic Hepatobiliary and Pancreatic Surgery.

Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

The Role of Indocyanine Green in Laparoscopic Low Anterior Resections for Rectal Cancer Previously Treated With Chemo-radiotherapy: A Single-center Retrospective Analysis.

AIM: Anastomotic leakage represents the most fearful complication in colorectal surgery. Important risk factors for leakage are low anastomoses and preoperative radiotherapy. Many surgeons often unnecessarily perform a protective ileostomy, increasing costs and necessitating a second operation for recanalization. The aim of this study was to evaluate the role of indocyanine green in assessing bowel perfusion, even in cases of a low anastomosis on tissue treated with radiotherapy. PATIENTS AND METHODS: Two groups of patients were selected: Group A (risky group) with only low extraperitoneal rectal tumors (<8 cm) previously treated with neoadjuvant chemo-radiotherapy; group B (no risk group) with only intraperitoneal rectal tumors (>8 cm), not previously treated with neoadjuvant therapy. Clinical postoperative outcome, morbidity, mortality and anastomotic leakage were compared between these two groups. RESULTS: In group A, comprised of 35 patients, the overall complication rate was 8.6%, with two patients developing anastomotic leakage (5.7%). In group B, comprised of 53 patients, the overall complication rate was 17% with four cases with anastomotic leakage (7.5%). No statistical difference was observed for conversion rate, general complications, or anastomotic leakage. No statistical differences were observed in clinical variables except for American Society of Anesthesiologist score (p=0.04). Patients who developed complications during radiotherapy had no significant differences in postoperative outcomes compared with other patients. CONCLUSION: Indocyanine green appears to be safe and effective in assessing the perfusion of colorectal anastomoses, even in the highest-risk cases, potentially reducing the rate of ileostomy. The main limitation remains the lack of a universally replicable standard assessment.

Effect of fluid strategy on stroke volume, cardiac output, and fluid responsiveness in adult patients undergoing major abdominal surgery: a sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial.

BACKGROUND: We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. METHODS: Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. RESULTS: Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m-2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min-1 m-2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). CONCLUSIONS: The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. CLINICAL TRIAL REGISTRATION: ACTRN12615000125527.

Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities.

BACKGROUND: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. METHODS: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. RESULTS: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916). CONCLUSION: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.

[Future trend of minimally invasive surgery platform and surgical procedure].

In the past 30 years, minimally invasive surgery has been greatly improved with the development of the energy platform, instrument platform, and imaging platform. Taking colorectal cancer surgery as an example, the five elements of surgical procedure have developed to a certain extent. The surgical approach has undergone a process from large to small. The range of resection ranges from simple bowel resection to radical resection/extended radical resection, and then to surgery that focuses on preserving organ function. With the recognition of the direction of normal lymphatic drainage and the characteristics of tumor lymphatic metastasis, lymph node dissection has been gradually standardized. The reconstruction of the digestive tract has changed from manual sutures to full endoscopic anastomosis, and then to the concept of functional anastomosis. The removal of the specimen has improved from large incision through the abdominal wall, to small laparoscopic incision, and then to the natural cavity. The evolution of these procedures depends on the advancement of technology platforms and equipment, and the recognition of new concepts. The development of minimally invasive platform must be in the direction of ensuring the implementation of the most optimized surgical approach. The platform is more secure, integrated, multifunctional, and intelligent. In the future, minimally invasive procedures must be aimed at maximizing the benefits of patients. The procedures are more scientific, functional, comfortable and diverse. Surgical innovation has promoted the development of the platform. The platform and the surgical procedure promote each other's development.

Delivery of digestive surgery services during the COVID-19 pandemic: Indonesian Society of Digestive Surgeons online survey.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, digestive surgery potentially exposes both health-care professionals and vulnerable patients to COVID-19. A survey was conducted with aim to determine the digestive surgery services provided during the COVID-19 pandemic, optimize safety for patients and clinicians, and safeguard health-care services. METHODS: An online survey was conceived and circulated to members of the Indonesian Society of Digestive Surgeons. The survey was conducted in two phases, in April 2020 and July 2020, to evaluate changes in response to the COVID-19 pandemic. RESULTS: Early in the pandemic (April 2020), the median number of major digestive surgeries performed monthly declined from 20 cases (range. 3-100 cases) to 1 case (range. 0-10 cases) (P < .001; Wilcoxon signed-rank test). Most of the cases in April 2020 addressed emergency problems, but more definitive surgeries were performed during the later period of the survey. The importance of screening for COVID-19 with polymerase chain reaction has increased over time, and a more comprehensive screening methodology incorporating real-time polymerase chain reaction, chest CT, and rapid antibody test were evident in 31.37% of July 2020 responses. CONCLUSION: Our survey has shown that surgeons adapted to the evolving pandemic and continue to do so only with appropriate safety assurances.

Trends in the diffusion of robotic surgery in prostate, uterus, and colorectal procedures: a retrospective population-based study.

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

Development of gastroenterological surgery over the last decade in Japan: analysis of the National Clinical Database.

The National Clinical Database (NCD) of Japan was established in 2010 with the board certification system. A joint committee of 16 gastroenterological surgery database-affiliated organizations has been nurturing this nationwide database and utilizing its data for various analyses. Stepwise board certification systems have been validated by the NCD and are used to improve the surgical outcomes of patients. The use of risk calculators based on risk models can be particularly helpful for establishing appropriate and less invasive surgical treatments for individual patients. Data obtained from the NCD reflect current developments in the surgical approaches used in hospitals, which have progressed from open surgery to endoscopic and robot-assisted procedures. An investigation of the data acquired by the NCD could answer some relevant clinical questions and lead to better surgical management of patients. Furthermore, excellent surgical outcomes can be achieved through international comparisons of the national databases worldwide. This review examines what we have learned from the NCD of gastroenterological surgery and discusses what future developments we can expect.

New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update.

Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives.

Advances in the diagnosis and management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a multifaceted disorder encompassing a family of syndromes attributable to, or exacerbated by, gastroesophageal reflux that impart morbidity, mainly through troublesome symptoms. Major GERD phenotypes are non-erosive reflux disease, GERD hypersensitivity, low or high grade esophagitis, Barrett's esophagus, reflux chest pain, laryngopharyngeal reflux, and regurgitation dominant reflux. GERD is common throughout the world, and its epidemiology is linked to the Western lifestyle, obesity, and the demise of Helicobacter pylori. Because of its prevalence and chronicity, GERD is a substantial economic burden measured in physician visits, diagnostics, cancer surveillance protocols, and therapeutics. An individual with typical symptoms has a fivefold risk of developing esophageal adenocarcinoma, but mortality from GERD is otherwise rare. The principles of management are to provide symptomatic relief and to minimize potential health risks through some combination of lifestyle modifications, diagnostic testing, pharmaceuticals (mainly to suppress or counteract gastric acid secretion), and surgery. However, it is usually a chronic recurring condition and management needs to be personalized to each case. While escalating proton pump inhibitor therapy may be pertinent to healing high grade esophagitis, its applicability to other GERD phenotypes wherein the modulating effects of anxiety, motility, hypersensitivity, and non-esophageal factors may dominate is highly questionable.

Temporal Trends in Surgical Resection Rates and Biologic Prescribing in Crohn's Disease: A Population-based Cohort Study.

BACKGROUND: The use of biologic therapy for Crohn's disease [CD] continues to evolve, however, the effect of this on the requirement for surgery remains unclear. We assessed changes in biologic prescription and surgery over time in a population-based cohort. METHODS: We performed a retrospective cohort study of all 1753 patients diagnosed with CD in Lothian, Scotland, between January 1, 2000 and December 31, 2017, reviewing the electronic health record of each patient to identify all CD-related surgery and biologic prescription. Cumulative probability and hazard ratios for surgery and biologic prescription from diagnosis were calculated and compared using the log-rank test and Cox regression analysis stratified by year of diagnosis into cohorts. RESULTS: The 5-year cumulative risk of surgery was 20.4% in cohort 1 [2000-2004],18.3% in cohort 2 [2005-2008], 14.7% in cohort 3 [2009-2013], and 13.0% in cohort 4 [2014-2017] p <0.001. The 5-year cumulative risk of biologic prescription was 5.7% in cohort 1, 12.2% in cohort 2, 22.0% in cohort 3, and 44.9% in cohort 4 p <0.001. CONCLUSIONS: The increased and earlier use of biologic therapy in CD patients corresponded with a decreasing requirement for surgery over time within our cohort. This could mean that adopting a top-down or accelerated step-up treatment strategy may be effective at reducing the requirement for surgery in newly diagnosed CD.

Part Three of Three-Part Series: Colorectal Surgery Review for Primary Care Providers.

Malignant colon and rectal disorders must be identified and treated. Timing and indication for diagnostic and screening colonoscopy are extremely important. A high index of suspicion to exclude malignancy is imperative. This paper will focus on the screening for and treatment of colorectal and anal cancers.

Oncological colorectal surgery during the COVID-19pandemic-a national survey.

PURPOSE: The aim of this study was to clarify the surgical supply situation of oncological colorectal patients in Germany during limitations of the OR caseload due to the COVID-19 pandemic. METHODS: Between 11th and 19th April 2020, all members of a consortium of German colorectal cancer centers were invited to participate in a web-based survey on the current status of surgical care situation of colorectal cancer patients in Germany. RESULTS: A total of 112 colorectal surgeons of 101 German hospitals participated in the survey. Eighty-seven percent of the participating hospitals had to reduce their total surgical caseload and 34% their surgical volume for oncological colorectal patients during COVID-19 pandemic. Restrictions of the surgical caseload were independent of the size of the hospital and the number of cases of COVID-19 in the federal state of the hospital. Sixteen percent of colorectal surgeons consider surgical limitations to be not justified and 78% to be justified only if the care of oncological patients is ensured. Ninety-five percent of the colorectal surgeons interviewed stated that all oncological colorectal patients with an indication for surgery should be operated in time, despite the current reservations for COVID-19 patients. For the majority of the respondents (63% and 51%, respectively), an extended waiting time for surgery of up to 2 weeks was acceptable for non-metastatic and metastatic patients, respectively. CONCLUSION: In Germany, there is a temporarily relevant reduction of surgical volume in oncological colorectal patients. Most colorectal surgeons stated that oncological colorectal surgery should not be compromised despite the measures taken during the COVID-19 pandemic.

[Promoting the colorectal surgery in virtue of new theories and techniques].

Since the 21st century, with the development of minimally invasive surgical technology, the update of comprehensive treatment strategies and the progress of clinical research, colorectal surgery has developed rapidly. However, in recent years, some disputable issues still exist in colorectal surgery, such as transanal total mesorectal excision, pelvic cavity lateral lymph node dissection, the "wait and observe" strategy for clinical complete remission of rectal cancer after neoadjuvant therapy, and robotic colorectal surgical operation. In addition, the application of three dimensions imaging, 4K resolution, 5th generation wireless systems, virtual reality, artificial intelligence and other new techniques may provide extensive space and new opportunity for the development of colorectal surgery. The therapic outcome could be optimized by more relevant clinical research and evidence, which contribute to the standardization of surgical treatment of colorectal cancer.

Recent Trends and Overall Survival of Young Versus Older Adults With Stage II to III Rectal Cancer Treated With and Without Surgery in the United States, 2010-2015.

BACKGROUND: The omission of surgery via nonoperative management (NOM) for rectal cancer may be increasing, and this strategy could be particularly attractive for younger patients, whose incidence of rectal cancer has been rising. We sought to assess trends in NOM in young (younger than 55 y) versus older adult (55 y and older) rectal cancer cohorts. METHODS: The National Cancer Database was used to identify patients diagnosed with stage II to III rectal cancer between 2010 and 2015. Multivariable logistic regression defined the association between sociodemographic variables and odds of NOM, including an age (18 to 54 vs. 55+ y)×surgery (surgery vs. NOM) interaction term. Adjusted Cox regression models compared overall survival between NOM versus surgery. RESULTS: Among 22,561 patients with a median follow-up of 37.5 months, the utilization rate of NOM increased from 10.7% (2010) to 15.2% (2015). Older patients were more likely to receive NOM, although rates also increased among young (7.1% to 10.6%). Black patients were also more likely to receive NOM (P<0.001). Among the entire cohort, NOM was associated with worse overall survival (adjusted hazard ratio [AHR]=2.90, 95% confidence interval [CI]: 2.67-3.15) and there was a statistically significant age×NOM interaction (P=0.01) such that the effect of NOM on survival was worse for younger (AHR=3.37, 95% CI: 2.82-4.02) as compared with older patients (AHR=2.49, 95% CI: 2.27-2.74). CONCLUSIONS: The increasing trend for NOM in stage II to III rectal cancer may be driven by disparities in treatment. Management with NOM appears to be associated with poorer survival, particularly in younger patients and could worsen outcomes for groups already at risk for suboptimal cancer care.

National trends in bowel and upper abdominal procedures in ovarian cancer surgery.

OBJECTIVES: In the United States, trends in the initial treatment approach for ovarian cancer reflect a shift in paradigm toward the increased use of neoadjuvant chemotherapy and interval cytoreductive surgery. The aim of this study was to evaluate the trends in surgical cytoreductive procedures in ovarian cancer patients who underwent either primary or interval cytoreductive surgery. METHODS: This retrospective, population-based study examined patients with stage III/IV ovarian cancer diagnosed between January 2000 and December 2013 identified using SEER-Medicare. Small or large bowel resection, ostomy creation, and upper abdominal procedures were identified using relevant billing codes and compared over time. A 1:1 primary and interval cytoreductive propensity matched cohort was created using demographic and clinical variables. 30-day complications and the use of acute care services were compared. RESULTS: A total of 5417 women were identified. 34% underwent bowel resections, 16% ostomy creation, and 8% upper abdominal procedures. There was an increase in bowel resections and upper abdominal procedures from 2000 to 2013 in patients who underwent primary cytoreductive surgery. Compared with patients who received primary cytoreduction, patients who underwent interval cytoreductive surgery were less likely to undergo bowel resection (OR=0.50; 95% CI [0.41, 0.61]) or ostomy creation (OR=0.48; 95% CI [0.42, 0.56]). Upper abdominal procedures did not differ between groups. For patients who underwent primary cytoreductive surgery, these procedures were associated with intensive care unit stay (4.6% vs <2%, P<0.01). In both primary and interval cytoreductive surgery patients, the receipt of bowel and upper abdominal procedures was associated with multiple 30-day postoperative complications and higher rates of readmission and emergency room visits. CONCLUSIONS: The performance of upper abdominal procedures in ovarian cancer patients increased from 2000 to 2013. Interval cytoreductive surgery was associated with decreased likelihood of bowel surgery. In matched primary and interval cytoreductive surgery cohorts, the receipt of these procedures were associated with the increased likelihood of postoperative complications and use of acute care services.