Short-term Outcomes of Ambulatory Colectomy for 157 Consecutive Patients.

OBJECTIVE: To evaluate short-term outcomes of laparoscopic colectomy for selected consecutive patients in an ambulatory setting at two institutions. BACKGROUND: Several studies showed that an enhanced recovery protocol for colorectal surgery reduces postoperative morbidity and mortality, and shortens the length of hospital stay. The development of such a program has allowed us to gradually reduce the length of stay for colorectal surgery, until ambulatory management. METHODS: Between February, 2013 and December, 2016, all patients scheduled for elective laparoscopic colectomy and meeting rigorous criteria for ambulatory surgery were included. Outcome was prospectively studied. RESULTS: One hundred fifty-seven patients (70 women) with a median age of 61 years (range 25-82 years) were included. The ambulatory rate for colectomy was 30.5%. Median operative time and length of in-hospital stay were 95 minutes (range 45-232 minutes) and 10.0 hours (range 7-14.7 hours), respectively. The admission rate was 7.0% due to operative difficulties (4 patients), medical reasons (4 patients), and social reasons (3 patients). Outcomes for these patients were uneventful and the median length of hospital stay was 3.1 days (range 1-14 days). An unscheduled consultation was necessary for 30 patients (20.5%). Nine patients required readmission (6.1%), of whom 6 required reoperation (3.8%). The overall 30-day morbidity rate was 24.8%. The mortality rate was 0%. CONCLUSIONS: This is the first case of consecutive patients undergoing ambulatory colectomy for malignant or benign disease. We demonstrated the feasibility, safety, and reproducibility of outpatient colectomy for selected patients. In our experience, 30% of patients scheduled for elective colectomy can be managed in an ambulatory setting.

Lack of recovery in monocyte human leukocyte antigen-DR expression is independently associated with the development of sepsis after major trauma.

INTRODUCTION: Major trauma is characterized by an overwhelming pro-inflammatory response and an accompanying anti-inflammatory response that lead to a state of immunosuppression, as observed after septic shock. Diminished monocyte Human Leukocyte Antigen DR (mHLA-DR) is a reliable marker of monocyte dysfunction and immunosuppression. The main objective of this study was to determine the relation between mHLA-DR expression in severe trauma patients and the development of sepsis. METHODS: We conducted a prospective observational study over 23 months in a trauma intensive care unit at a university hospital. Patients with an Injury Severity Score (ISS) over 25 and age over 18 were included. mHLA-DR was assessed by flow cytometry protocol according to standardized protocol. Mann-Whitney U-test for continuous non-parametric variables, independent paired t test for continuous parametric variables and chi-square test for categorical data were used. RESULTS: mHLA-DR was measured three times a week during the first 14 days. One hundred five consecutive severely injured patients were monitored (ISS 38 ± 17, SAPS II 37 ± 16). Thirty-seven patients (35%) developed sepsis over the 14 days post-trauma. At days 1-2, mHLA-DR was diminished in the whole patient population, with no difference with the development of sepsis. At days 3-4, a highly significant difference appeared between septic and non-septic patients. Non- septic patients showed an increase in mHLA-DR levels, whereas septic patients did not (13,723 ± 7,766 versus 9,271 ± 6,029 antibodies per cell, p = .004). Most importantly, multivariate logistic regression analysis, after adjustment for usual clinical confounders (adjusted OR 5.41, 95% CI 1.42-20.52), revealed that a slope of mHLA-DR expression between days1-2 and days 3-4 below 1.2 remained associated with the development of sepsis. CONCLUSIONS: Major trauma induced an immunosuppression, characterized by a decrease in mHLA-DR expression. Importantly, after multivariate regression logistic analysis, persistent decreased expression was assessed to be in relation with the development of sepsis. This is the first study in trauma patients showing a link between the lack of immune recovery and the development of sepsis on the basis of the standardized protocol. Monitoring immune function by mHLA-DR measurement could be useful to identify trauma patients at a high risk of infection.

Should ambulatory appendectomy become the standard treatment for acute appendicitis?

Background: Appendectomy is increasingly performed as a 'short stay' or 'ambulatory' procedure, yet there is no consensus for selection of patients with acute appendicitis for ambulatory surgery (AS). We aimed to compare characteristics and outcomes of complicated and uncomplicated appendectomies performed in ambulatory vs. conventional settings, and to determine factors associated with unexpected re-consultations and re-hospitalizations. Methods: The authors reviewed a consecutive series of 185 laparoscopic appendectomies. Whenever possible, patients were offered AS, defined as 'discharge on the same working day.' Multivariable regressions were performed to determine associations of unexpected re-consultations and re-hospitalizations with surgery type (ambulatory or conventional) and patient characteristics (age, gender, obesity, symptoms, appendicolith, perforations, appendix diameter, serologic results, American Society of Anesthesiologists score, and Saint-Antoine score). Results: From the initial cohort, 117 patients (63.2%) were eligible for AS, of which 8 had peri- or post-operative contraindications. Therefore, 109 patients (58.9%) were operated by AS, with median length of stay 8.5 h (range, 3.3-20.5). Ambulatory cases had a lower incidence of complications (11.9%) than conventional cases (25.0%) (p = 0.029). Uni- and multi-variable regressions revealed that unexpected re-consultations were not significantly associated with any of the pre- or peri-operative variables but that unexpected re-hospitalizations were 4 times more likely for patients with appendicolith (OR, 4.32; p = 0.04). Conclusions: Ambulatory surgery could be considered as a standard procedure for both complicated and uncomplicated acute appendicitis. Appendicolith was found to be an independent risk factor for unexpected re-hospitalization and should therefore trigger closer monitoring.

Experience with an Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery: Comparison of MGB and LSG in 374 Patients.

BACKGROUND: Strategic multidisciplinary protocols for "enhanced recovery after surgery" (ERAS) have demonstrated reductions in length of hospital stay (LOS), morbidity, and costs in conjunction with bariatric procedures. METHODS: We prospectively investigated the effectiveness and safety of an ERAS protocol with laparoscopic omega loop gastric bypass ("mini" gastric bypass, MGB) and LSG in morbidly obese patients. RESULTS: Average LOS was 1.24 days (range 1-14); 86.1% discharged on day 1; 96.9% by day 2, a value comparable or better than that of other ERAS studies vs standard care according to meta-analysis. Complications 2.9%; readmission 2.1%; reintervention 1.3%. CONCLUSION: The program was equally safe with both procedures. Postoperative antithrombotic heparin does not appear necessary in low-risk patients. Bariatric surgical ERAS programs are evolving and not yet standardized.

Early coagulopathy in trauma patients: an on-scene and hospital admission study.

PURPOSE: Amongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients. METHODS: Prospective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured. RESULTS: The median injury severity score was 25 (13-35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group (p=.02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status (p<.0001) and changes in other coagulation parameters. Patients with base deficit ≤-6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy. CONCLUSION: Coagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion.