Necessity of routine perioperative epidural catheter placement in laparoscopic colorectal resections: a retrospective data analysis.

PURPOSE: Whether epidural anesthesia leads to further improvement in the postoperative course of colorectal procedures is under discussion. The aim of this study was to evaluate the effects of minimally invasive colorectal oncological interventions without epidural anesthesia (EDA). METHODS: This retrospective data analysis included the clinical data of all patients who underwent minimally invasive oncological colorectal resection at our clinic between January 2013 and April 2019. Of 385 patients who met the inclusion criteria, 183 (group I; 47.5% of 385) received EDA, and 202 (group II; 52.5% of 385) received transversus abdominis plane block instead. The relevant target parameters were evaluated and compared between the groups. The postoperative complications were graded according to the Clavien-Dindo classification. RESULTS: The patients in group I (n=183; women, 77; men, 106; age 66.8 years) were younger (p=0.0035), received a urinary catheter more often (99.5% versus [vs.] 28.2% p<0.001), required longer, more frequent arterenol treatment (1.1 vs. 0.6 days; p<0.001), and had a longer intermediate care unit stay than those in group II (2.8 vs. 1.1 days; p<0.001). Postoperative pain levels were not significantly different between the groups (p=0.078). The patients in group I were able to ambulate later than those in group II (4 vs. 2 days; p<0.001). The difference in the postoperative day of the first defecation was not significant between the groups (p=0.236). The incidence of postoperative complications such as bleeding (p=0.396), anastomotic leaks (p=0.113), and wound infections (p=0.641) did not differ between the groups. The patients in group I had significantly longer hospital stays than those in group II (12.2 vs. 9.4 days; p<0.001). CONCLUSION: EDA can be safely omitted from elective minimally invasive colorectal resections, and its omission is not accompanied by any relevant disadvantages to the patient.

Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections?

PURPOSE: Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL. METHODS: All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma). RESULTS: A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions). CONCLUSION: In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases.

PURPOSE: In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group. METHODS: Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence. RESULTS: One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection). CONCLUSION: Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Laparoscopic rectal resection without epidural catheters-does it work?

PURPOSE: Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness and with an increased risk of bladder emptying disorders and a decrease in blood pressure, which all relate to delayed mobilization. Preliminary data shows that EC placement may not be necessary for laparoscopic colon resections. The aim of this prospective study was to investigate how the omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections. METHODS: All laparoscopic rectal resections occurring between 2013 and 2020 were prospectively examined. Resections from January 2013 to February 2018 (group A) were compared with resections from March 2018 to December 2020 (group B; after the internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain > 3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, intermediate care unit stay (IMC stay) in days, and hospital length of stay in days. RESULTS: In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay was significantly lower in group B (p < 0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo. CONCLUSION: Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.