The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis.

INTRODUCTION: We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018. METHODS: A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes. RESULTS: From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates. CONCLUSION: When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.

Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases.

INTRODUCTION: We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis. METHODS: Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications. RESULTS: Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578). CONCLUSION: Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients.

BACKGROUND: The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach. METHODS: Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate. RESULTS: A total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site. CONCLUSION: The NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

A national evaluation of the predictors of compliance and survival from adjuvant chemotherapy in high-risk stage II colon cancer: A National Cancer Database (NCDB) analysis.

BACKGROUND: Guidelines recommend adjuvant chemotherapy for stage II colon cancer with high-risk features, but there has been little study on compliance with guidelines. This work sought to evaluate compliance with adjuvant chemotherapy and factors associated with compliance in high-risk stage II colon cancer. This work's hypothesis was that compliance with adjuvant chemotherapy recommendations is low, but improves overall survival when used. METHODS: The National Cancer Database was reviewed for stage II high-risk colon cancers that underwent curative resection from 2010 to 2017. The cases were stratified into adjuvant chemotherapy and no adjuvant chemotherapy cohorts. A multivariate logistic regression identified factors associated with adjuvant chemotherapy compliance. Propensity-score matching was performed to balance the cohorts and Kaplan-Meier analysis assessed overall survival. The main outcome measures were adjuvant chemotherapy compliance, factors associated with compliance, and overall survival in high-risk stage II colon cancer. RESULTS: A total of 52,609 patients were evaluated, and 23.2% received adjuvant chemotherapy. The factors associated with noncompliance included older age (odds ratio 0.919; 95% confidence interval 0.915-0.922; P < .001), Medicaid (odds ratio 0.720; 95% confidence interval 0.623-0.832; P < .001) payor, greater comorbidities (odds ratio 0.423; 95% confidence interval 0.334-0.530; P < .001), and residing in the Midwest (odds ratio 0.898; 95% confidence interval 0.812-0.994; P = .037). All of the known high-risk features were significantly independently associated with compliance. In a matched cohort, adjuvant chemotherapy significantly improved the 5-year overall survival (78.1% vs 66.6%; P < .001). CONCLUSION: Nationally, there is low compliance with adjuvant chemotherapy in high-risk stage II colon cancer. Despite the low compliance, adjuvant chemotherapy was associated with improved overall survival. Demographic variables were associated with poor compliance, whereas tumor factors were associated with increased compliance. These results highlighted the disparities in care and opportunities to improve outcomes in high-risk stage II colon cancer.

Robotic NICE Procedure Using Handsewn Technique.

INTRODUCTION: In 2018, we described a robotic natural orifice-assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the natural orifice intracorporeal anastomosis with transrectal extraction procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis. We present a technical video and initial experience depicting the unique steps to accomplish this procedure with colorectal end-to-end handsewn anastomosis. TECHNIQUE: Twenty natural orifice intracorporeal anastomosis with transrectal extraction procedures with end-to-end handsewn intracorporeal anastomosis were performed. A video depicting the essential steps with 2 variations of the handsewn techniques is presented along with short-term outcomes. RESULTS: The most common indication was complicated diverticulitis followed by rectal cancer and deep infiltrative endometriosis of the rectum. The mean operative time was 235 minutes (99-294 min), and there were no intraoperative complications or conversions. Handsewn end-to-end intracorporeal anastomosis was successful in all patients. Natural orifice transrectal extraction was successful in 17 of 20 (85%) patients. The mean postoperative length of stay was 2.1 days (±1.05 SD). There were 3 major complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both patients required readmission and were treated with antibiotics alone. One patient, who had a diverting ileostomy performed at the time of the index procedure, developed subclinical dehiscence of the anastomosis, which healed without intervention but resulted in a delay in ileostomy reversal. There were no additional readmissions and no reoperations or mortalities. CONCLUSIONS: Robotic natural orifice intracorporeal anastomosis with transrectal extraction procedure and colorectal end-to-end handsewn anastomosis was feasible and safe in this initial series. This technique can be successfully performed in a total intracorporeal manner without the need for an abdominal wall extraction incision or any circular stapling devices.

Real-World Data on Liposomal Bupivacaine and Inpatient Hospital Costs After Colorectal Surgery.

INTRODUCTION: This study compared costs of care among colorectal surgery patients who received liposomal bupivacaine versus those who did not (control) from a health institution perspective. MATERIAL AND METHODS: This pharmacoeconomic evaluation was conducted among adults undergoing open or minimally invasive colorectal resection at an academic medical center from May 2016 to February 2018. Healthcare resource utilization was derived from the electronic health record. Total cost of care (2018 USD) was analyzed using a generalized linear model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, height, cancer, and age. The primary analysis used public costs. A sensitivity analysis used internal costs from the hospital to maximize internal validity. RESULTS: Of 486 included patients, 286 (59%) received liposomal bupivacaine. Total cost of care using public costs included perioperative local anesthetics (mean ± standard deviation [SD]: $392 ± 74 liposomal bupivacaine versus $8 ± 13 control), analgesics within 48 h after surgery (mean ± SD: $132 ± 99 liposomal bupivacaine versus $117 ± 127 control), postoperative ileus management (mean ± SD: $5 ± 51 liposomal bupivacaine versus $65 ± 284 control), and hospital length of stay (mean ± SD: $4459 ± 3576 liposomal bupivacaine versus $7769 ± 7082 control). Liposomal bupivacaine was associated with an adjusted absolute difference in total cost of care of -$1435 (95% confidence interval -$2401 to -$470; P = 0.004) using public costs and -$1345 (95% confidence interval -$2215 to -$476; P = 0.002) using internal costs. CONCLUSIONS: Use of liposomal bupivacaine in colorectal surgery was associated with a significant reduction in total cost of care that was predominately driven by reduced costs for hospital stay and postoperative ileus management despite higher medication costs.

A national evaluation of the use and survival impact of adjuvant chemotherapy in Stage II colon cancer from the national cancer database.

AIM: Stage II colon cancers are a heterogeneous category, with controversy over use of adjuvant chemotherapy (AC). Patients with high-risk features may benefit from AC to improve overall survival (OS). Current guidelines do not routinely recommend AC in low-risk cases, but the actual use and benefit on OS in this cohort have not been fully examined on a national scale. We aimed to evaluate the use and impact of AC on OS in low-risk Stage II colon cancer. METHODS: The national cancer database was reviewed for Stage II colon cancers undergoing curative resection (2010-2015). Cases with preoperative radio-chemotherapy or high-risk features were excluded. Cases were stratified into 'AC' and 'no AC' cohorts, and then propensity score matched. Kaplan-Meier and Cox regression analysed OS. The main outcome measures were the incidence and impact of AC on OS in low-risk Stage II colon cancer. RESULTS: Of 39 926 patients evaluated, 8.2% (n = 3275) received AC. Matching resulted in 3275 cases per cohort. AC significantly improved 1-, 3- and 5-year OS versus no AC (P = 0.0017). The 5-year absolute risk reduction was 2.6%, relative risk reduction 12%, with a number needed to treat of 38. In the Cox model, AC remained significantly associated with increased OS (hazard ratio 0.816; 95% CI 0.713-0.934; P < 0.003). CONCLUSIONS: From this dataset, AC was associated with improved OS in low-risk Stage II disease. These findings from a large-scale sample question current guidelines and the need for better risk stratification. Further study with more robust variables is warranted to determine AC best practices.

Colorectal cancer in the 45-to-50 age group in the United States: a National Cancer Database (NCDB) analysis.

BACKGROUND: Amid increasing awareness of early-onset colorectal cancer (CRC), guidelines in the United States (US) recently lowered the recommended routine CRC screening age from 50 to 45 in average-risk individuals. There are little data on the number of patients in this age group diagnosed with CRC prior to these changes. Our objective was to audit the historic CRC case trends and impact of CRC in the 45-to-50-year-old category prior to new screening recommendations. METHODS: Colorectal adenocarcinoma cases in 45-to-50-year-old patients were queried from the NCDB (2004-2017). Cases were stratified by sex, race, and site. The disability-adjusted lost years (DALY) and lost earnings were estimated. The average annual percentage changes (AAPC) of CRC incidence were estimated using jointpoint analysis. The main outcome measures were DALY and lost earnings. Secondary outcome measures were the 2004-2017 AAPC and the cumulative incidence of potential CRC cases in the 45-to-50 cohort through 2030 without guideline changes. RESULTS: 67,442 CRC patients in the 45-to-50 demographic were identified. The CRC burden resulted 899,905 DALY and $17 billion in lost earnings. The 2004-2017 AAPC was 1.6%, with an estimated 13-year increase of 25%. There were sex-, race-, and anatomic site-specific discrepancies with estimated 13-year increases of 30% for males, 110% for American Indian/ Alaska Natives/ Asian American/ Pacific Islander races, and 31% for rectal cancer by 2030. CONCLUSION: CRC has been steadily increasing in the 45-to-50 age group, with tremendous disability and cost ensuing. There is great potential benefit from lowering the recommended routine CRC screening age to 45. Targeted intervention could ensure the most vulnerable segments benefit from the new guidelines, in both reducing the incidence and improving survivorship in CRC patients.

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis.

BACKGROUND: Totally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort. METHODS: Consecutive, elective, unselected patients presenting with complicated diverticulitis defined as fistula, abscess and stricture underwent the NICE procedure over a 24-month period. Demographic and intraoperative data were collected, and video recordings were reviewed and edited on encrypted server. RESULTS: A total of 60 patients (50% female) underwent the NICE procedure for complicated diverticulitis with a mean age of 58.9 years and mean BMI of 30.7 kg/m2. The mean operative time was 231.6 min. All cases (100%) were achieved with intracorporeal anastomosis using a circular stapling device. All but one patient (98.3%) had successful transrectal extraction of the specimen. Forty-four (73%) of the specimens required a specimen-thinning maneuver to successfully extract the specimen and there were no conversions. We identified seven key technical modifications and considerations to facilitate successful completion of the procedure which are illustrated, including early release of the disease, mesentery-sparing dissection, dual instrument control of the mesenteric vasculature, release of the rectal reflection, use of NICE back table, specimen-thinning maneuver, and closure of the rectal cuff. CONCLUSION: We present a stepwise approach with key modifications to successfully achieve totally robotic intracorporeal resection for those presenting with complicated diverticulitis. This approach may help overcome the technical challenges and provide a foundation for reproducible results.

Opioid-Sparing Effect of Liposomal Bupivacaine and Intravenous Acetaminophen in Colorectal Surgery.

BACKGROUND: This study evaluated the opioid-sparing effect of liposomal bupivacaine and intravenous acetaminophen in colorectal surgery. MATERIALS AND METHODS: This study was a retrospective, 2 × 2 factorial cohort conducted at an academic medical center from May 2016 to February 2018. Patients undergoing open or minimally invasive colorectal resection were included. Exclusion criteria were age <18 y, surgery after second hospital day, ostomy, and allergy to acetaminophen, opioids, or bupivacaine. Intraoperative liposomal bupivacaine and intravenous acetaminophen administration within 18 h after surgery were evaluated. The primary outcome was intravenous morphine milligram equivalents administered within 24 h after surgery. A linear regression model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, and height was used for the primary analysis. RESULTS: Among 486 included patients, 193 received both liposomal bupivacaine and intravenous acetaminophen, 93 received liposomal bupivacaine only, 104 received intravenous acetaminophen only, and 96 did not receive either. On average, patients received 21 (SD = 31) morphine equivalents over 24 h. Intraoperative liposomal bupivacaine was associated with a reduction of morphine equivalents (adjusted change -11, 95% CI -17 to -6), but intravenous acetaminophen was not (2, 95% CI -3 to 7). Intraoperative liposomal bupivacaine was associated with a reduction of length of stay (adjusted change = -1.2 d, 95% CI -2.1 to -0.3), but intravenous acetaminophen was not (adjusted change = 1.5 d, 95% CI 0.7 to 2.2). CONCLUSIONS: Liposomal bupivacaine was associated with a significant reduction of opioid use within 24 h after colorectal surgery, but intravenous acetaminophen was not.

Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure.

Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures; however technical challenges have limited this approach following conventional laparoscopic surgery. The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided ICA, however, there are no reports involving more complex left-sided procedures such as diverticulitis. Furthermore, there are no reports of natural orifice-assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed transrectally, thereby completely eliminating the need for an abdominal wall incision other than for port sites. We present a pilot study to investigate the safety, feasibility and short-term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure. Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database. All patients underwent the robotic NICE procedure. Demographic data, intraoperative data and outcomes data were assessed and analyzed. Ten patients (five males and five females) underwent resection. The mean age and BMI were 56 years (43-66) and 29 kg/m2 (21-35). All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA. The mean operative time was 198 min (146-338) and mean EBL was 35 ml (15-50). Mean time to first flatus was 16 h (10-22) and mean length of stay was 1.9 days (1.6-2.6). There were no intraoperative or postoperative complications. There was no unexpected ICU stay, reoperation or readmission. Colorectal left-sided resections such as for diverticulitis were safely accomplished using natural orifice-assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study. The NICE procedure resulted in early return of bowel function, short length of stay and low complication. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

Robotic left-sided colorectal resection with natural orifice IntraCorporeal anastomosis with extraction of specimen: The NICE procedure. A pilot study of consecutive cases.

BACKGROUND: Despite numerous benefits, only a small fraction of laparoscopic left-sided colectomy is accomplished without the need for an abdominal incision to retrieve the specimen and prepare for anastomosis. We report our early experience with a robotic approach using Natural orifice IntraCorporeal anastomosis with Extraction of specimen (NICE) to help overcome the technical limitations and challenges of this approach. METHODS: Twenty consecutive patients presented for elective sigmoid or rectosigmoid resection for benign and malignant disease and underwent the NICE procedure. Safety, feasibility and post-operative outcomes were analyzed. RESULTS: Intracorporeal anastomosis was accomplished in all patients. One patient required an abdominal incision to extract a bulky tumor. Mean operative time was 222 min (146-344). Mean time to first flatus and length of stay was 23 and 49 h, respectively. All but 4 patients were discharged home on post-operative day 2. One patient was readmitted with a pelvic fluid collection. CONCLUSION: Robotic left-sided colorectal resection with NICE procedure is a safe and feasible minimally invasive approach and may facilitate greater adoption rates of this technique.

Impact of long-acting local anesthesia on clinical and financial outcomes in laparoscopic colorectal surgery.

BACKGROUND: Our objective was to assess clinical and financial outcomes with long-acting liposomal bupicavaine (LB) in laparoscopic colorectal surgery. METHODS: Patients that received local infiltration with LB were strictly matched to a control group, and compared for postoperative pain, opioid use, length of stay (LOS), hospital costs, and complication, readmission, and reoperation rates. RESULTS: A total of 70 patients were evaluated in each cohort. Operative times and conversion rates were similar. LB patients had lower post-anesthesia care unit pain scores (P = .001) and used less opioids through postoperative day 3 (day 0 P < .01; day 1 P = .03; day 2 P = .02; day 3 P < .01). Daily pain scores were comparable. LB had shorter LOS (mean 2.96 vs 3.93 days; P = .003) and trended toward lower readmission, complication, and reoperation rates. Total costs/patient were $746 less with LB, a savings of $52,200 across the cohort. CONCLUSIONS: Using local wound infiltration with LB, opioid use, LOS, and costs were improved after laparoscopic colorectal surgery. The additional medication cost was overshadowed by the overall cost benefits. Incorporating LB into a multimodal pain regiment had a benefit on patient outcomes and health care utilization.

A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits.

BACKGROUND: The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery. METHODS: A Truven MarketScan® claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region. RESULTS: A total of 4615 colectomies were included-2054 (44.5 %) open and 2561 (55.5 %) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p < 0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9 % open vs. 2.0 % MIS, p < 0.001), higher overall complications (52.8 % open vs. 32.3 % MIS, p < 0.001), higher colorectal-specific complications (32.5 % open vs. 17.9 % MIS, p < 0.001), longer LOS (6.39 open vs. 4.44 days MIS, p < 0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p < 0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p = 0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution. CONCLUSIONS: In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.

Transversus abdominis plane blocks: pilot of feasibility and the learning curve.

BACKGROUND: Our goal was to evaluate the learning curve for transversus abdominis plane (TAP) block placement and identify issues that impede successful placement. METHODS: Three novices were prospectively evaluated performing ultrasound-guided TAP blocks in 10 consecutive patients. Operators were assessed on medication knowledge, setup/placement, procedural steps, and performance time. Times were compared to an expert for efficiency and competence. The main outcome measures were procedures needed for competence and variables associated with increased coaching/procedure time. RESULTS: In the 30 patient sample, the mean body mass index (BMI) was 30.9 (standard deviation [SD], 5.79). Fifteen patients were obese (BMI > 30), seven (23.3%) super obese (BMI > 35), and 15 had prior abdominal surgery. The mean setup time was 107.5 s (SD, 87), right-side placement was 131.8 s (SD, 60.3), left-side placement 114.8 s (SD, 40.5), and total time 354 s (SD, 111). By the second attempt, all operators were fluent in the medication and setup. At block 3, operators 1 and 3 reached competence in performance time; by block 4, all three operators reached time competence. After reaching competence, outliers in procedure times were only experienced for extremes in BMI (<20 and >35). Additional coaching was needed in four patients with prior abdominal surgery to decipher the correct planes. CONCLUSIONS: Based on our pilot, by four attempts, novices reach appropriate speeds with progressively less coaching to safely and efficiently place TAP blocks. Extremes of BMI and prior abdominal surgery impact procedural time and may required additional coaching to facilitate placement. Given the promising results, further work on developing best practices for education and implementation is warranted.

Is there value in alvimopan in minimally invasive colorectal surgery?

BACKGROUND: Alvimopan's goal is to minimize postoperative ileus and optimize outcomes; however, evidence in laparoscopic surgery is lacking. Our goal was to evaluate the benefit of alvimopan in laparoscopic colorectal surgery with an enhanced recovery pathway (ERP). METHODS: Laparoscopic colorectal cases were stratified into alvimopan and control cohorts, then case-matched for comparability. All followed an identical ERP. The main outcomes were length of stay, complications, readmissions, and costs in the alvimopan and control groups. RESULTS: About 321 patients were analyzed in each cohort. Operative times were comparable (P = .08). Postoperatively, complication rates were similar (P = .29), with no difference in ileus (P = 1.00). The length of stay (3.69 vs 3.49 days; P = .16), readmission (2.8% vs 3.7%; P = .66) and reoperation rates (2.2% vs 1.6%; P = .77) were comparable for alvimopan and controls, respectively. Total costs were similar ($14,932.47 alvimopan vs $14,846.56 controls; P = .90), but the additional costs in the alvimopan group could translate to savings of $27,577 in the cohort. CONCLUSIONS: Alvimopan added no benefit in patient outcomes in laparoscopic colorectal surgery with an ERP. These results could drive a change in current practice. Controlled studies are warranted to define the cost and/or benefit in clinical practice.