Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy.

AIM: Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]). METHODS: This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used. RESULTS: The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity. CONCLUSION: Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis.

PURPOSE: The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA). METHODS: MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model. RESULTS: Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes. CONCLUSIONS: Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.

Are the recommendations for post-operative antibiotics in patients with grade I or II acute calculous cholecystitis being applied in clinical practice?

BACKGROUND: There is a level-1 evidence indicating that postoperative antibiotics are unnecessary following cholecystectomy for grade I or II acute calculous cholecystitis (ACC). We wanted to evaluate the applications of this recommendation in clinical practice four years after the original publication in ABCAL-participating centers. METHODS: A retrospective analysis of patients operated for grade I or II ACC from January to December 2016 in ABCAL-participating centers was performed. Inclusion criteria were the same as for the ABCAL-study. The primary endpoint was the postoperative antibiotic administration rate. The secondary endpoints were postoperative outcomes. RESULTS: Of the 283 patients included, 64% received postoperative antibiotics. Only 19% received antibiotics after POD1. The perioperative outcomes were similar between those that did or did not receive antibiotics after POD1. The median [range] length of stay was significantly shorter in patients who did not receive postoperative antibiotics (4 days [1-20]) compared to the others (6 days [1-50], p > 0.001). CONCLUSION: Despite strong recommendations included in the Tokyo 2018 guidelines, the results of the ABCAL-study are poorly applied even if the absence of postoperative antibiotics has no impact on morbidity. It is important to stress that postoperative antibiotics are not necessary after cholecystectomy for grade I or II ACC.

Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial.

IMPORTANCE: Ninety percent of cases of acute calculous cholecystitis are of mild (grade I) or moderate (grade II) severity. Although the preoperative and intraoperative antibiotic management of acute calculous cholecystitis has been standardized, few data exist on the utility of postoperative antibiotic treatment. OBJECTIVE: To determine the effect of postoperative amoxicillin plus clavulanic acid on infection rates after cholecystectomy. DESIGN, SETTING, AND PATIENTS: A total of 414 patients treated at 17 medical centers for grade I or II acute calculous cholecystitis and who received 2 g of amoxicillin plus clavulanic acid 3 times a day while in the hospital before and once at the time of surgery were randomized after surgery to an open-label, noninferiority, randomized clinical trial between May 2010 and August 2012. INTERVENTIONS: After surgery, no antibiotics or continue with the preoperative antibiotic regimen 3 times daily for 5 days. MAIN OUTCOMES AND MEASURES: The proportion of postoperative surgical site or distant infections recorded before or at the 4-week follow-up visit. RESULTS: An imputed intention-to-treat analysis of 414 patients showed that the postoperative infection rates were 17% (35 of 207) in the nontreatment group and 15% (31 of 207) in the antibiotic group (absolute difference, 1.93%; 95% CI, -8.98% to 5.12%). In the per-protocol analysis, which involved 338 patients, the corresponding rates were both 13% (absolute difference, 0.3%; 95% CI, -5.0% to 6.3%). Based on a noninferiority margin of 11%, the lack of postoperative antibiotic treatment was not associated with worse outcomes than antibiotic treatment. Bile cultures showed that 60.9% were pathogen free. Both groups had similar Clavien complication severity outcomes: 195 patients (94.2%) in the nontreatment group had a score of 0 to I and 2 patients (0.97%) had a score of III to V, and 182 patients (87.8%) in the antibiotic group had a score of 0 to I and 4 patients (1.93%) had a score of III to V. CONCLUSIONS AND RELEVANCE: Among patients with mild or moderate calculous cholecystitis who received preoperative and intraoperative antibiotics, lack of postoperative treatment with amoxicillin plus clavulanic acid did not result in a greater incidence of postoperative infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01015417.

[Ureteral obstruction and Crohn's disease]. / Obstruction urétérale et maladie de Crohn.

Noncalculous ureteral obstructions in Crohn's disease are often asymptomatic and unidentified. Occurring in about 3% of patients, they occur on the right side in more than 70% of cases, because of frequently associated ileocecal disease. If they are associated with inflammation or fibrosis of retroperitoneal periureteral fat nephrectomy may become necessary. Conservative treatment should be considered first, with urine drainage (ureteral stent, or percutaneous nephrostomy), diet, and corticotherapy. However bowel resection is often necessary during follow up. If this fails to cure the ureteral obstruction, ureterolysis should be performed. We report the case of a 32 year old woman with noncalculous ureteral obstruction revealing Crohn's disease.

A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis.

OBJECTIVES: To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults (≥75) with those of younger adults undergoing early (<5 days after onset of complaints) cholecystectomy. DESIGN: Retrospective analysis from May 2010 to August 2012. SETTING: Randomized, multicenter, clinical trial (ABCAL Study, NCT01015417). PARTICIPANTS: Individuals with mild or moderate acute calculous cholecystitis (ACC) according to the Tokyo Guidelines (N=414; n=78 aged 75-94, median 82; n=336 aged 18-74, median 49). MEASUREMENTS: Demographic characteristics and pre-, intra-, and postoperative data. RESULTS: The elderly group was more likely to have an American Society of Anesthesiologists score of 3 or greater (62% vs 23%, P<.001), higher serum creatinine (103 vs 74 µmol/L, P<.001), and more-severe ACC (moderate ACC (62% vs 50%, P=.05), gangrenous cholecystitis (38% vs 15%, P=.001)) on preoperative imaging and confirmed intraoperatively. Ulcerated mucosa (76% vs 61%, P=.001) was significantly more frequent in the elderly group. Operative time, postoperative mortality, and postoperative infectious (18% vs 14%, P=.35) and noninfectious (9% vs 3%, P=.80) complications were similar between the two groups. Median length of stay (7.0 vs 5.0 days, P=.54) and readmission rate (15% vs 4%, P=.07) were not significantly higher in the elderly group. No significant difference was observed for the subgroup of participants aged 80 and older. CONCLUSION: In this randomized trial that included a selected sample of older adults, there was no difference in major outcomes between elderly adults and their younger counterparts after early cholecystectomy. The findings are limited because important geriatric outcomes such as delirium and functional decline were not examined.