Nationwide Outcomes After Neoadjuvant Chemotherapy for Locally Advanced Sigmoid Colon Cancer-A Propensity Score-Matched Analysis.

BACKGROUND: The role of neoadjuvant chemotherapy (NAC) in advanced sigmoid colon carcinoma remains to be further characterized. Rationale for NAC includes downstaging on final pathology and optimization of microscopically negative margins (R0 resection). We investigated rates of neoadjuvant chemotherapy use in advanced sigmoid colon cancer at academic cancer centers and assessed factors associated with likelihood of NAC administration. METHODS: The National Cancer Database was queried from 2004 to 2017 for patients with clinical T3 or T4, N0-2, M0 sigmoid colon cancer who underwent surgical resection. Those with neoadjuvant radiation or metastatic disease were excluded. The outcomes of patients who did and did not receive neoadjuvant chemotherapy were evaluated for this retrospective cohort study. RESULTS: There were 23,597 patients of whom 364 (1.5%) received NAC. More patients received NAC at academic (41%, P < .001) and high-volume centers (27%, P < .001). Patients with Medicare/Medicaid (39%) and private insurance (52%) were more likely to receive NAC (P < .001). There was a significantly higher rate of N2 to N1 downstaging in the NAC group. Propensity-score matching demonstrated comprehensive community cancer programs (CCCP) were less likely to provide NAC (OR 0.4; 95% CI 0.23, 0.70, P < .001). There was no difference in survival (P = .20), R0 resection (P = .090), or 30-day readmission rates (P = .30) in the NAC cohort compared to the non-NAC cohort. CONCLUSIONS: Access to centers offering multi-disciplinary care with NAC prior to surgical resection is important. This care was associated with academic and high-volume centers and private or government-sponsored insurance. There was no difference in survival between NAC and non-NAC cohort.

Long-term urogenital assessment after elective laparoscopic sigmoid resection for diverticulitis: a comparison between central and peripheral vascular resection.

AIM: Increasing attention has been given to postoperative gastrointestinal functional outcome and quality of life after sigmoid resection for diverticulitis. Conversely, very little has been described about postoperative urogenital functional outcome and even less about its potential relationship to the type of vascular approach. The aim of this study was to evaluate whether central ligation of the inferior mesenteric artery (IMA) compared with peripheral dissection could impair urinary and sexual function in the long term. METHOD: Patients undergoing elective laparoscopic sigmoid resection for diverticulitis from 2004 to 2017 were retrospectively analysed. They were asked to complete the American Urological Association Symptom Index (AUASI) questionnaire. Men received the five-item version of the International Index of Erectile Function (IIEF-5) questionnaire. Patients were then divided according to the type of vascular resection. RESULTS: A response rate of the 36.4% to the AUASI and 43.8% to the IIEF-5 questionnaires was achieved. Three hundred and twenty four patients with a mean age of 62 ± 9.85 years were analysed for their urinary function (IMA preserved n = 217; IMA resected n = 107) in a median follow-up of 87 months. Furthermore, 115 men with a mean age of 60 ± 8.97 years were investigated for their sexual function (IMA preserved n = 80; IMA resected n = 35) in a median follow-up of 89 months. No difference (AUASI: 8 ± 6.32 IMA preserved vs. 7 ± 6.26 IMA resected, P = 0.204; IIEF-5: 15 ± 7.67 IMA preserved vs. 15 ± 8.61 IMA resected, P = 0.674) was found regarding the type of vascular approach during sigmoid resection. CONCLUSIONS: No association was found between the type of vascular approach and the long-term urogenital functional outcome in patients undergoing sigmoid resection for diverticulitis.

Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial.

BACKGROUND: Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial. METHODS: This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively. RESULTS: Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840). CONCLUSION: Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

ANTECEDENTES: Se han publicado varios estudios en favor de la sigmoidectomía con anastomosis primaria (primary anastomosis, PA) sobre la intervención de Hartmann (Hartmann's procedure, HP) para la diverticulitis perforada con peritonitis purulenta o fecal (Hinchey grado III ó IV), pero apenas existe información de los resultados relacionados con el coste. Por lo tanto, el presente estudio tuvo como objetivo evaluar los costes y el coste efectividad del brazo DIVA en el ensayo clínico Ladies. MÉTODOS: Se realizó un análisis de coste-efectividad del brazo DIVA del ensayo clínico multicéntrico y aleatorizado Ladies, que comparó PA y HP para la diverticulitis Hinchey de grado III ó IV. Durante un seguimiento de 12 meses, se recogieron datos prospectivamente del uso de recursos, costes indirectos (SF-HLQ) y calidad de vida (EQ-5D), y se analizaron de acuerdo con una modificación del principio por intención de tratar. Los resultados principales fueron la relación coste-efectividad incremental (incremental cost-effectiveness ratio, ICER) y la relación coste-utilidad incremental (incremental cost-utility ratio, ICUR), expresados como la razón del incremento de costes y el incremento en la probabilidad de no requerir estoma o años de vida ajustados por calidad, respectivamente. RESULTADOS: En total, se incluyeron 130 pacientes, 64 de los cuales fueron asignados a PA (Hinchey III/IV: 46/20) y 66 a HP (Hinchey III/IV: 46/18). Los costes medios globales por paciente fueron más bajos para la PA (€20.544 (i.c. del 95%: 19.569 a 21.519)) en comparación con HP (€ 28.670 (i.c. del 95%: 26.636 a 30.704)), con una diferencia media de €−8.126 (i.c. del 95% −14.660 a −1.592)). Además, se observó un ICER de € −39.094 (95% bias-corrected and accelerated boodstrap confidence interval, BCaCI −1.213 a −116), lo que indica que PA es más coste efectiva. El ICUR fue € −101.435 (BCaCI del 95%: −1.113.264 a 251.840). CONCLUSIÓN: La anastomosis primaria es más rentable que el procedimiento de Hartmann para la diverticulitis perforada con peritonitis purulenta o fecal.

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database.

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Splenic flexure mobilization for sigmoid and low anterior resections in the minimally invasive era: How often and at what cost?

BACKGROUND: Splenic flexure mobilization (SFM) increases left colonic reach for a better vascularized and tension-free anastomosis. Open SFM is challenging due to anatomic position. Minimally invasive SFM improves visualization and minimizes splenic traction. METHODS: We retrospectively reviewed all sigmoid and low anterior resections (LAR) by a colorectal surgical group over 10-year period. We analyzed indications, surgical methods and perioperative outcomes of open and MIS SFM cohorts. RESULTS: 793 patients were included; 122 (15.5%) open, 671 (84.5%) MIS (60% laparoscopic-assisted (LA), 40% hand-assisted (HA)). Overall, indications were cancer (56%), diverticulitis (31%), and other benign diseases (13%). Compared to MIS, open cases had more complex disease (45% vs. 18%, p < 0.01), with fewer SFM performed (40% vs. 86%, p < 0.01), required more frequent diversion (30% vs. 21%, p = 0.02) and were complicated by higher leak/abscess (7% vs. 3%, p = 0.06) and reoperation rates (10% vs. 6%, p = 0.11). 1% of SFM required conversion (LA to HA 0.5%, MIS to open 0.5%). There were no open SFM complications. There were 26 (5%) MIS SFM complications; bleeding (18; 12 splenic capsular tears (0 splenectomy/splenorraphy), 6 mesenteric) and organ injury (bowel (3), pancreatic (4), renal (1)). CONCLUSIONS: Our SFM rate was high in the MIS group, with a low overall complication rate. Of note, the anastomotic leak/abscess rate was 3%, and may be related to the high SFM rate. It is the authors' opinion that a major advantage of MIS is to facilitate SFM, hence SFM is more likely to be performed with these methods compared to open procedures.

The MicroHand S robotic-assisted versus Da Vinci robotic-assisted radical resection for patients with sigmoid colon cancer: a single-center retrospective study.

BACKGROUND: Sigmoid colon cancer is a lethal disease and has a strong indication for surgery. Robotic-assisted surgery is one of the promising alternative treatment for this disease. Nowadays, the MicroHand S surgical system and the Da Vinci surgical system have been assembled in China. However, there is still no report to study the therapeutic effects of the two robotic-assisted surgical systems. Thus, the purpose of this study was to compare clinical and economic outcomes of patients with sigmoid colon cancer undergoing robot-assisted radical surgery via The MicroHand S or Da Vinci surgical system. METHODS: The clinical data of 45 patients with sigmoid colon cancer undergoing the MicroHand S or Da Vinci robotic-assisted surgery at The Third Xiangya Hospital of Central South University from January 2017 to January 2019 were retrospectively analyzed. RESULTS: Twenty-one patients received MicroHand S robotic-assisted radical surgery and 24 patients received Da Vinci robot-assisted radical surgery. No significant differences were observed in terms of operation time, number of lymph node harvested, blood loss, intestinal exhaust time, time of oral feeding resumption, volume of abdominal cavity 24-h drainage, hospital stay, complication and rate of conversion, removal time of drainage tube and catheter between MicroHand S and Da Vinci group. However, the MicroHand S group had significantly lower hospitalization costs (P = 0.002) and shorter time to get out of bed after surgery (P = 0.04). In addition, no recurrence and metastases were observed in both groups during the follow-up. CONCLUSIONS: In patients with sigmoid colon cancer, the Da Vinci surgical system did not show obvious clinical advantages compared to the MicroHand S surgical system in surgical outcomes. However, the MicroHand S surgical platform showed advantages in terms of the hospitalization costs and length of postoperative bedtime. The outcome of this study will probably result in a shift to the MicroHand S surgical system as treatment preference in China.

Cost-effectiveness analysis of a multicentre randomized clinical trial comparing surgery with conservative management for recurrent and ongoing diverticulitis (DIRECT trial).

BACKGROUND: The results of the DIRECT trial, an RCT comparing conservative management with elective sigmoid resection in patients with recurrent diverticulitis or persistent complaints, showed that elective sigmoid resection leads to higher quality of life. The aim of this study is to determine the cost-effectiveness of surgical treatment at 1- and 5-year follow-up from a societal perspective. METHODS: Clinical effectiveness and resource use were derived from the DIRECT trial. The actual resource use and quality of life (EQ-5D-3L™ score) were documented prospectively per individual patient and analysed according to the intention-to-treat principle for up to 5 years after randomization. The main outcome was the incremental cost-effectiveness ratio (ICER), expressed as costs per quality-adjusted life-year (QALY). RESULTS: The study included 106 patients, of whom 50 were randomized to surgery and 56 to conservative treatment. At 1- and 5-year follow-up an incremental effect (QALY difference between groups) of 0·06 and 0·43 respectively was found, and an incremental cost (cost difference between groups) of €6957 and €2674 respectively, where surgery was more expensive than conservative treatment. This resulted in an ICER of €123 365 per additional QALY at 1-year follow-up, and €6275 at 5 years. At a threshold of €20 000 per QALY, operative treatment has 0 per cent probability of being cost-effective at 1-year follow-up, but a 95 per cent probability at 5 years. CONCLUSION: At 5-year follow-up, elective sigmoid resection in patients with recurring diverticulitis or persistent complaints was found to be cost-effective. Registration number: NTR1478 (www.trialregistrer.nl).

Economic Disparities in Patients Undergoing Sigmoidectomy.

BACKGROUND AND OBJECTIVES: Disparities in health care outcomes and resources utilized are present in the treatment of many conditions and represent an area for targeted improvement. This study analyzes the differences in outcomes and total hospital charges between the highest and lowest income quartiles of patients undergoing sigmoid colectomy. METHODS: This retrospective cohort study included patients undergoing sigmoid colectomy from 2013 to 2014 queried from the Agency for Healthcare Research and Quality National Inpatient Sample Database who were categorized as the lowest and highest income quartile based on average income of the patient's ZIP code. Patients were grouped into income quartiles, as defined by average income in the ZIP code of residence. In-hospital complications were the primary outcome of this study. We hypothesized that patients in the lowest income quartile would have poorer outcomes than those in the highest income quartile prior to data collection. RESULTS: The lowest (n = 40,995) and highest (n = 40,940) income quartiles are not significantly different based on age or gender. The lowest income quartile was sicker, with higher mean scores for the All Patient Refined Diagnosis Related Group Severity Index and All Patient Refined Diagnosis Related Group Risk of Mortality Index. The lowest income quartile cohort had higher rates of postoperative complications and higher total charges than those in the highest income quartile. Adjusted regression analysis showed significantly lower total charges for the lowest income quartile but no significant differences in overall complications, mortality rates, or nonhome discharge. CONCLUSIONS: Patients in the highest income quartile utilize more hospital resources than the lowest income quartile. Additional study is required to understand why these differences exist. KEY POINTS: 1. Significant differences in outcomes and hospital charges exist between socioeconomic groups undergoing sigmoidectomy. 2. There does not seem to be a difference in outcomes after sigmoidectomy among different socioeconomic groups. 3. Elective and laparoscopic sigmoid colectomy is more frequently applied to higher socioeconomic groups. 4. Hospital charges are also greater among patients of higher socioeconomic groups undergoing sigmoid colectomy. QUESTION: Does socioeconomic status affect outcomes and total charges in patients undergoing sigmoid colectomy? FINDINGS: Unadjusted analysis showed significant disparities between the highest and lowest income quartile in outcomes after sigmoid colon resection. Adjusted analysis showed no difference in outcomes, with patients in the highest income quartile having higher total charges. MEANING: There is a value difference between high-income and low-income patients undergoing sigmoid colectomy.

High-Risk Colorectal Surgery: What Are the Outcomes for Geriatric Patients?

The population is aging and more geriatric patients are undergoing surgery. The national burden and age-specific outcomes of previously defined high-risk colorectal procedures (HRCP) remain unknown. Using the 2014 National Inpatient Sample, patients were stratified into nongeriatric (NG, <65 years), younger geriatric (YG, 65-79 years), and older geriatric (OG, ≥80 years) cohorts. Cases were grouped into nonelective admissions (NA) and elective admissions (EA). Nationally representative outcomes were compared across age group and admission type. Of 215,425 patients undergoing HRCP, 47.3 per cent were ≥65 years. During NA and EA, inpatient mortality, discharge to nursing facility, and median postoperative length of stay increased with each increasing age category (P < 0.001). Outcomes during NA were worse than EA in all age groups (P < 0.001). For example, rates of discharge to nursing facility were 13.4 per cent NG, 39.4 per cent YG, and 64.7 per cent OG during; NA and 3.1 per cent NG, 13.3 per cent YG, and 34 per cent OG during EA. During NA and EA, cost was equal in YG and OG but greater than in NG. Outcomes after HRCP are worse for older patients and for nonelective cases. This information can inform preoperative counseling and targeted quality improvement projects. Further work is needed to understand geriatric-specific risk factors and outcomes to provide high-quality patient-centered care.

Cost analysis of laparoscopic lavage compared with sigmoid resection for perforated diverticulitis in the Ladies trial.

BACKGROUND: Laparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study. METHODS: This study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention-to-treat) for up to 1 year after randomization. RESULTS: Eighty-eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € - 3512, 95 per cent bias-corrected and accelerated c.i. -16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € - 2509 to -4438). CONCLUSION: Laparoscopic lavage for perforated diverticulitis is more cost-effective than sigmoid resection.

The Use of Robotic and Laparoscopic Surgical Stapling Devices During Minimally Invasive Colon and Rectal Surgery: A Comparison.

PURPOSE: To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures. MATERIALS AND METHODS: We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate. RESULTS: Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001). CONCLUSION: This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.

Variation in Hospital-Specific Rates of Suboptimal Lymphadenectomy and Survival in Colon Cancer: Evidence from the National Cancer Data Base.

BACKGROUND: Little is known about between-hospital differences in the rate of suboptimal lymphadenectomy. This study characterizes variation in hospital-specific rates of suboptimal lymphadenectomy and its effect on overall survival in a national hospital-based registry. METHODS: Stage I-III colon cancer patients were identified from the 2003-2012 National Cancer Data Base. Bayesian multilevel logistic regression models were used to assess the impact of patient- and hospital-level factors on hospital-specific rates of suboptimal lymphadenectomy (<12 lymph nodes), and multilevel Cox models were used to estimate the effect of suboptimal lymphadenectomy at the patient (yes vs. no) and hospital level (quartiles of hospital-specific rates) on overall survival. RESULTS: A total of 360,846 patients across 1345 hospitals in the US met the inclusion criteria, of which 25 % had a suboptimal lymphadenectomy. Wide variation was observed in hospital-specific rates of suboptimal lymphadenectomy (range 0-82 %, median 44 %). Older age, male sex, comorbidity score, no insurance, positive margins, lower tumor grade, lower T and N stage, and sigmoid and left colectomy were associated with higher odds of suboptimal lymphadenectomy. Patients treated at lower-volume and non-academic hospitals had higher odds of suboptimal lymphadenectomy. Patient- and hospital-level factors explained 5 % of the between-hospital variability in suboptimal lymphadenectomy, leaving 95 % unexplained. Higher suboptimal lymphadenectomy rates were associated with worse survival (quartile 4 vs. quartile 1: hazard ratio 1.19, 95 % confidence interval 1.16-1.22). CONCLUSION: Large differences in hospital-specific rates of suboptimal lymphadenectomy were observed, and this variation was associated with survival. Quality improvement initiatives targeting hospital-level adherence to the national standard may improve overall survival among resected colon cancer patients.

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery.

BACKGROUND: Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery. METHODS: The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach. RESULTS: A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group. CONCLUSIONS: Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

[Single port laparoscopic colostomy using the glove technique]. / Colostomía laparoscópica por puerto único con técnica de guante.

The single port surgery with glove technique is a novel process, suitable to the present day economic and technological moment. Colostomies are surgical interventions suitable to its application. We describe the surgical method and outcome of patients who underwent colostomy by single port glove technique within the years 2011 and 2012, in two hospitals in Asturias, Spain. We carried out six sigmoid colostomies. Four patients had tumoral pathology, another a perineal necrotizing fasciitis, and the sixth, a patient with Crohn's disease and complex perianal fistulas. The average age of the patients, four men and two women, was 54 years (range 42-67 years). The average intervention time was 42 minutes (range 30-65 minutes). There were no complications during the surgery or in the postoperative period. In our facilities material expenditure was reduced to half as regards other conventional single port devices. The glove technique represents the most economic and least invasive approach for the surgical procedure of stomas, in our experience considered a simple, safe and easily reproducible technique.

Colostomía laparoscópica por puerto único con técnica de guante / Single port laparoscopic colostomy using the glove technique

La cirugía por puerto único con técnica de guante (glove port) es un abordaje adecuado al momento económico y tecnológico que vivimos. Entre las intervenciones susceptibles de su aplicación está la realización de colostomías. Describimos la técnica quirúrgica y resultados de los pacientes a los que se realizó colostomía por puerto único con técnica de guante, a lo largo de los años 2011 y 2012, en dos hospitales de Asturias, España. Realizamos seis colostomías sigmoideas. Cuatro pacientes presentaban enfermedad tumoral, otro caso fue por una fascitis necrosante perineal, y el sexto un paciente con enfermedad de Crohn y fístulas perianales complejas. La edad media de los pacientes, cuatro hombres y dos mujeres, fue de 54 años (rango 42-67 años). El tiempo medio de intervención fue de 42 minutos (rango 30-65 minutos). No hubo complicaciones durante la cirugía ni en el postoperatorio. En nuestro medio, el gasto en material se redujo a la mitad con respecto a otros dispositivos convencionales de puerto único. La técnica de guante representa el abordaje por puerto único más económico y mínimamente invasivo para la realización de estomas, siendo en nuestra experiencia una técnica sencilla, segura y fácilmente reproducible.

The single port surgery with glove technique is a novel process, suitable to the present day economic and technological moment .Colostomies are surgical interventions suitable to its application. We describe the surgical method and outcome of patients who underwent colostomy by single port glove technique within the years 2011 and 2012, in two hospitals in Asturias, Spain. We carried out six sigmoid colostomies. Four patients had tumoral pathology, another a perineal necrotizing fasciitis, and the sixth, a patient with Crohn's disease and complex peri-anal fistulas. The average age of the patients, four men and two women, was 54 years (range 42-67 years). The average intervention time was 42 minutes (range 30-65 minutes). There were no complications during the surgery or in the postoperative period. In our facilities material expenditure was reduced to half as regards other conventional single port devices. The glove technique represents the most economic and least invasive approach for the surgical procedure of stomas, in our experience considered a simple, safe and easily reproducible technique.

Orthotopic sigmoid vs. ileal neobladders in Japanese patients: a comparative assessment of complications, functional outcomes, and quality of life.

OBJECTIVES: To compare the clinical outcomes of sigmoid and ileal neobladders (NBs) created following radical cystectomy. MATERIALS AND METHODS: This study included 90 and 144 Japanese patients undergoing radical cystectomy and orthotopic NB reconstruction with a sigmoid and ileal segment, respectively. Postoperative clinical outcomes between the sigmoid and ileal NB groups (SNBG and INBG) were compared. RESULTS: In this series, 110 early and 51 late complications occurred in 71 and 41 patients, respectively; however, there was no significant difference in the incidence of complications between SNBG and INBG. At 1 year postoperatively, there were no significant differences in the proportion of spontaneous voiders and the continence status between these 2 groups; however, despite the lack of significant differences in the maximal flow rate and voided volume, the post-void residual in SNBG was significantly smaller than that in INBG. Voiding functional outcomes at 5 years postoperatively were also obtained from 28 and 49 in SNBG and INBG, respectively. Although there were no significant changes in the functional outcomes in SNBG, the proportion of spontaneous voiders and post-void residual in INBG at 5 years postoperatively were significantly poorer than those at 1 year postoperatively. Furthermore, the postoperative health-related quality of life assessed by a Short-Form 36 survey did not show any significant differences in all 8 scores between these 2 groups. CONCLUSIONS: Both types of NB reconstruction resulted in comparatively satisfactory outcomes; however, the voiding function, particularly that on long-term follow-up, in SNBG appeared to be more favorable than that in INBG.

Proximal and distal colorectal cancer resection rates in the United States since widespread screening by colonoscopy.

BACKGROUND & AIMS: Screening decreases colorectal cancer (CRC) incidence and mortality. Colonoscopy has become the most common CRC screening test in the United States, but the degree to which it protects against CRC of the proximal colon is unclear. We examined US trends in rates of resection for proximal vs distal CRC, which reflect CRC incidence, in the context of national CRC screening data, before and since Medicare's 2001 decision to pay for screening colonoscopy. METHODS: We used the Nationwide Inpatient Sample, the largest US all-payer inpatient database, to estimate age-adjusted rates of resection for distal and proximal CRC, from 1993 to 2009, in adults. Temporal trends were analyzed using Joinpoint regression analysis. RESULTS: The rate of resection for distal CRC decreased from 38.7 per 100,000 persons (95% confidence interval [CI], 35.4-42.0) to 23.2 per 100,000 persons (95% CI, 20.9-25.5) from 1993 to 2009, with annual decreases of 1.2% (95% CI, 0.1%-2.3%) from 1993 to 1999, followed by larger annual decreases of 3.8% (95% CI, 3.3%-4.3%) from 1999 to 2009 (P < .001). In contrast, the rate of resection for proximal CRC decreased from 30.0 per 100,000 persons (95% CI, 27.4-32.5) to 22.7 per 100,000 persons (95% CI, 20.6-24.7) from 1993 to 2009, but significant annual decreases of 3.1% (95% CI, 2.3%-4.0%) occurred only after 2002 (P < .001). Rates of resection for CRC decreased for adults ages 50 years and older, but increased for younger adults. CONCLUSIONS: These findings support the hypothesis that population-level decreases in rates of resection for distal CRC are associated with screening, in general, and that implementation of screening colonoscopy, specifically, might be an important factor that contributes to population-level decreases in rates of resection for proximal CRC.

Assessment of the role of aptitude in the acquisition of advanced laparoscopic surgical skill sets: results from a virtual reality-based laparoscopic colectomy training programme.

PURPOSE: The surgeons of the future will need to have advanced laparoscopic skills. The current challenge in surgical education is to teach these skills and to identify factors that may have a positive influence on training curriculums. The primary aim of this study was to determine if fundamental aptitude impacts on ability to perform a laparoscopic colectomy. METHODS: A practical laparoscopic colectomy course was held by the National Surgical Training Centre at the Royal College of Surgeons in Ireland. The course consisted of didactics, warm-up and the performance of a laparoscopic sigmoid colectomy on thesimulator. Objective metrics such as time and motion analysis were recorded. Each candidate had their psychomotor and visual spatial aptitude assessed. The colectomy trays were assessed by blinded experts post procedure for errors. RESULTS: Ten trainee surgeons that were novices with respect to advanced laparoscopic procedures attended the course. A significant correlation was found between psychomotor and visual spatial aptitude and performance on both the warm-up session and laparoscopic colectomy (r > 0.7, p < 0.05). Performance on the warm-up session correlated with performance of the laparoscopic colectomy (r = 0.8, p = 0.04). There was also a significant correlation between the number of tray errors and time taken to perform the laparoscopic colectomy (r = 0.83, p = 0.001). CONCLUSION: The results have demonstrated that there is a relationship between aptitude and ability to perform both basic laparoscopic tasks and laparoscopic colectomy on a simulator. The findings suggest that there may be a role for the consideration of an individual's inherent baseline ability when trying to design and optimise technical teaching curricula for advanced laparoscopic procedures.

Impact of early or delayed elective resection in complicated diverticulitis.

AIM: To investigate the outcomes of early and delayed elective resection after initial antibiotic treatment in patients with complicated diverticulitis. METHODS: The study, a non-randomized comparison of the two approaches, included 421 consecutive patients who underwent surgical resection for complicated sigmoid diverticulitis (Hinchey classification  I-II) at the Department of Surgery, University Medical Center Hamburg-Eppendorf between 2004 and 2009. The operating procedure, duration of hospital and intensive care unit stay, outcome, complications and socioeconomic costs were analyzed, with comparison made between the early and delayed elective resection strategies. RESULTS: The severity of the diverticulitis and American Society of Anesthesiologists score were comparable for the two groups. Patients who underwent delayed elective resection had a shorter hospital stay and operating time, and the rate of successfully completed laparoscopic resections was higher (80% vs 75%). Eight patients who were scheduled for delayed elective resection required urgent surgery because of complications of the diverticulitis, which resulted in a high rate of morbidity. Analysis of the socioeconomic effects showed that hospitalization costs were significantly higher for delayed elective resection compared with early elective resection (9296 € ± 694 € vs 8423 € ± 968 €; P = 0.001). Delayed elective resection showed a trend toward lower complications, and the operation appeared simpler to perform than early elective resection. Nevertheless, delayed elective resection carries a risk of complications occurring during the period of 6-8 wk that could necessitate an urgent resection with its consequent high morbidity, which counterbalanced many of the advantages. CONCLUSION: Overall, early elective resection for complicated, non-perforated diverticulitis is shown to be a suitable alternative to delayed elective resection after 6-8 wk, with additional beneficial socioeconomic effects.