Is Hartmann's Pouch an Option in the Management of Acute Severe Ulcerative Colitis?

BACKGROUND: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann's pouch. The aim of this retrospective study was to investigate whether Hartmann's pouch may be a safe option. METHODS: Thirty-eight Hartmann's pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. RESULTS: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. CONCLUSIONS: Hartmann's pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty.

Multifactorial analysis of the learning curve for totally robotic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric operation worldwide for the surgical management of obesity. Totally robotic Roux-en-Y gastric bypass (TR-RYGBP) has been considered to be a better approach by some groups especially early in a surgeon's experience. However, the learning curve associated with TR-RYGBP has been poorly evaluated yet. The aim of this study was to evaluate the learning curve of patients who underwent TR-RYGBP. METHODS: This is a prospective study of 154 first consecutive patients undergoing TR-RYGBP to analyze the influence of surgeon experience, bedside first assistant, and patient factors on operative time and postoperative complications. To give a comprehensive view of success related to the learning process, a single hybrid variable was generated. Multivariate analysis predicted the risk factors for complications and operative time. A risk-adjusted cumulative sum analysis estimated the learning curve. RESULTS: The learning curve for TR-RYGBP was 84 cases. Case rank and first assistant level were independent predictors of total operative time. Overall 30-day postoperative morbidity rate was 33.1 % and decreased over time. Surgeon experience (OR 2.6; CI 95 [1.290 to 5.479]; p = 0.0081) and first assistant level (OR 2.42; CI 95 [1.197 to 4.895]; p = 0.0139) remained independent predictors of composite event (operative time and complications). CONCLUSIONS: This study identifed criteria that should be assessed in future studies about TR-RYGBP. Both surgeon experience and bedside first assistant level affected operative duration, but surgeon experience was the most significant factor in reducing complication rates.

Perioperative outcomes after totally robotic gastric bypass: a prospective nonrandomized controlled study.

BACKGROUND: Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass. METHODS: This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications. RESULTS: Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications. CONCLUSIONS: Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.