Epidemiology, pathophysiology and medical management of postoperative ileus in the elderly.

As the population of the Western world ages, the number of major surgical procedures performed in the elderly population will by necessity increase. Within virtually every surgical specialty, studies have shown that patients should not be denied surgery on the basis of chronological age alone. It has recently been recognized that physiological age is far more important within the decision-making algorithm as to whether or not to proceed with major surgery in the septuagenarian and octogenarian populations and beyond. Not unexpectedly, not only the results of these operations, but also the associated morbidities, are similar in older and younger populations. Therefore, it is not surprising that postoperative ileus (POI) affects patients of all ages. POI is a multifactorial condition that is exacerbated by opioid analgesics, bed rest and other conditions that may be rather prevalent in the postoperative elderly patient. Therefore, as major surgical interventions are considered in this population, appropriate assessment and, ideally, correction of any physiological disturbances should be undertaken along with implementation of standardized enhanced recovery protocols. Ideally, through this combined approach, an appreciable impact can be made on reducing POI while controlling postoperative pain and limiting postoperative thromboembolic, cardiopulmonary, cerebral and infectious complications. This article reviews the potential impact of pharmacological agents, laparoscopy and other manoeuvres on POI in the elderly.

Review of available methods of simulation training to facilitate surgical education.

The old paradigm of "see one, do one, teach one" has now changed to "see several, learn the skills and simulation, do one, teach one." Modern medicine over the past 30 years has undergone significant revolutions from earlier models made possible by significant technological advances. Scientific and technological progress has made these advances possible not only by increasing the complexity of procedures, but also by increasing the ability to have complex methods of training to perform these sophisticated procedures. Simulators in training labs have been much more embraced outside the operating room, with advanced cardiac life support using hands-on models (CPR "dummy") as well as a fusion with computer-based testing for examinations ranging from the United States medical licensure exam to the examinations administered by the American Board of Surgery and the American Board of Colon and Rectal Surgery. Thus, the development of training methods that test both technical skills and clinical acumen may be essential to help achieve both safety and financial goals.

Laparoscopic management of inflammatory bowel disease.

The goal of the surgical management of Crohn's disease is to improve quality of life. Surgical management is generally reserved for patients who developed complications of the disease or who are unresponsive to or develop complications from aggressive medical therapy. Friable mesentery, inflammatory phlegmons, fistulas, abscesses, and adhesions from previous surgeries pose a surgical challenge to the laparoscopic approach. The laparoscopic approach to terminal ileal Crohn's disease is feasible and safe even in cases complicated by fistulas with previous abdominal surgery or recurrent disease. This approach is associated with an increased operative time compared to laparotomy, however, offers significant advantages over open ileocolic resection in terms of pulmonary function, length of hospital stay, duration of postoperative ileus, cosmesis, postoperative small bowel obstruction, and early postoperative complications. Laparoscopy is also associated with decreased overall hospitalization costs and improved patient satisfaction. Therefore, the laparoscopic approach for patients with Crohn's disease should be considered as the preferred operative approach.

Laparoscopic versus open proctectomy for rectal cancer: patients' outcome and oncologic adequacy.

BACKGROUND: The aim of this study was to compare laparoscopic management of rectal cancer to open surgery. METHODS: The medical records of patients who underwent elective laparoscopic or open proctectomy for rectal cancer between November 2004 and July 2006 were retrospectively reviewed. RESULTS: Thirty-two patients in the laparoscopic group (LG) were matched for tumor location, stage, comorbidity, and type of surgical procedure to 50 patients in the open group (OG). There were no statistically significant differences between the groups relative to American Society of Anesthesiologists score or tumor, node, metastasis stage; however, body mass index and age of the LG were significantly lower compared with the OG (P<0.05). In the LG, the procedure was successfully laparoscopically completed in 28 patients (87.5%). The median operative time was 240 minutes in the LG and 185 minutes in the OG (P< 0.05). Overall morbidity was 25% and 38%, respectively (P=0.1), the median hospital stay was 6 days, and median time to first bowel movement was 3 days in the LG compared with 7 and 4 days in the OG, respectively (P=0.7 and 0.01, respectively). The number of identified lymph nodes, distal and radial margins were comparable between both groups. Median follow-up was 10 (1 to 18) months. CONCLUSIONS: Laparoscopic proctectomy for rectal cancer is feasible in 87.5% of patients and despite a longer operative time compared with laparotomy, is safe with the advantages of faster recovery of bowel function. This procedure does not compromise the oncologic adequacy of resection or significantly differ from open proctectomy relative to short-term outcomes.

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND: A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery. METHODS: Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s). RESULTS: 325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case. CONCLUSIONS: It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.