Redefining the role of routine postoperative bloodwork following uncomplicated bariatric surgery.

BACKGROUND: A quality improvement opportunity was identified to de-adopt the low-value care practice of routinely performing bloodwork for all patients undergoing elective bariatric surgery. While these patients are typically discharged on postoperative day 1 (POD1) after bloodwork is performed, it is uncommon for the discharge plan to change due to unexpected laboratory abnormalities alone. METHODS: Patients undergoing bariatric surgery between September 2020 and April 2021 only had POD1 bloodwork if there were perioperative clinical concerns, they had insulin-dependent diabetes, or they were therapeutically anticoagulated. Thirty-day Emergency Department (ED) visits and readmissions were monitored as balancing measures. Outcomes were compared to a control group that underwent bariatric surgery prior to September 2020 when POD1 laboratory testing was routinely performed. Financial and environmental costs were estimated based our institutional standards. RESULTS: The intervention group consisted of 303 patients: 248 (82%) Roux-en-Y gastric bypasses and 55 (18%) sleeve gastrectomies. Most patients (n = 256, 84.5%) did not have POD1 bloodwork. Twelve (3.9%) had bloodwork performed in violation of our protocol, of which none had a change in management based on the results. Of the 35 (12%) who had appropriately ordered bloodwork, 6 (2%) required a transfusion and 2 (0.7%) required a second surgery on the same admission for hemorrhage. Forty-four (14.5%) had 30-day ED visits of which 17 (5.6%) were within 7 days. Sixteen (5.3%) were readmitted. There were no significant differences between intervention and control groups in the rate of transfusion, second surgery, or 30-day ED visits. The avoidance of POD1 bloodwork saved approximately $6602.24 in lab processing fees alone and 512 test tubes. CONCLUSION: POD1 bloodwork can be safely avoided in the absence of clinical concerns. In addition to not significantly increasing postoperative complications, there were benefits from a financial cost, environmental impact, and patient discomfort perspective.

Paraesophageal hernia repair in elderly patients: outcomes from a 10-year retrospective study.

BACKGROUND: Laparoscopic surgery has become the preferred management for paraesophageal hernias (PEH); however surgical management versus watchful waiting remains controversial in older patients. METHODS: This retrospective study analyzed the outcomes of PEH repair in elderly patients surgically managed at The Ottawa Hospital over a 10-year period. Patients older than 60 years who underwent PEH repair were examined with respect to presentation, technique and associated complications. RESULTS: Despite similar demographics, our study groups showed significantly different characteristics of surgical techniques. Most surgeries were performed laparoscopically; however, patients aged 70 years or older underwent more open and emergency surgeries than the younger group. Despite a 30-day postoperative complication rate of 45 % and 13 % in the older (≥ 70 yr) and younger (60-69 yr) groups, respectively, the rates during elective repair were similar. There were no deaths in the younger group, whereas the 30-day mortality rate was 5 % in patients aged 70 years and older, including a 2-fold increase with emergency repair (4 v. 2 patients). CONCLUSION: Management of PEH in older adults remains controversial in relation to a surgical versus watchful waiting approach. We found that in patients aged 70 years and older who undergo surgical management of PEH experience more open and emergency procedures, which are associated with higher complication rates. However, in the elective setting older patients had increased laparoscopic repairs and comparable complication rates to younger patients. We found the greatest outcomes with early, elective laparoscopic repair, irrespective of age.

Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study.

BACKGROUND: Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes. METHODS: We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively. RESULTS: One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups. CONCLUSION: Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration: ClinicalTrials.gov no. NCT02154763.

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass: Optimal CT Signs for Diagnosis and Clinical Decision Making.

Purpose To evaluate the accuracy of computed tomography (CT) for diagnosis of internal hernia (IH) in patients who have undergone laparoscopic Roux-en-Y gastric bypass and to develop decision tree models to optimize diagnostic accuracy. Materials and Methods This was a retrospective, ethics-approved study of patients who had undergone laparoscopic Roux-en-Y gastric bypass with surgically confirmed IH (n = 76) and without IH (n = 78). Two radiologists independently reviewed each examination for the following previously established CT signs of IH: mesenteric swirl, small-bowel obstruction (SBO), mushroom sign, clustered loops, hurricane eye, small bowel behind the superior mesenteric artery, and right-sided anastomosis. Radiologists also evaluated images for two new signs, superior mesenteric vein (SMV) "beaking" and "criss-cross" of the mesenteric vessels. Overall impressions for diagnosis of IH were recorded. Diagnostic accuracy and interobserver agreement were calculated, and multivariate recursive partitioning was performed to evaluate various decision tree models by using the CT signs. Results Accuracy and interobserver agreement regarding the nine CT signs of IH showed considerable variation. The best signs were mesenteric swirl (sensitivity and specificity, 86%-89% and 86%-90%, respectively; κ = 0.74) and SMV beaking (sensitivity and specificity, 80%-88% and 94%-95%, respectively; κ = 0.83). Overall reader impression yielded the highest sensitivity and specificity (96%-99% and 90%-99%, respectively; κ = 0.79). The decision tree model with the highest overall accuracy and sensitivity included mesenteric swirl and SBO, with a diagnostic odds ratio of 154 (95% confidence interval [CI]: 146, 161), sensitivity of 96% (95% CI: 87%, 99%), and specificity of 87% (95% CI: 75%, 93%). The decision tree with the highest specificity included SMV beaking and SBO, with a diagnostic odds ratio of 105 (95% CI: 101, 109), sensitivity of 90% (95% CI: 79%, 95%), and specificity of 92% (95% CI: 83%, 97%). Conclusion The decision tree with the highest accuracy and sensitivity for diagnosis of IH included mesenteric swirl and SBO, the model with the highest specificity included SMV beaking and SBO, and the remaining signs showed lower accuracy and/or poor to fair interobserver agreement. Overall reader impression yielded the highest accuracy for diagnosis of IH, likely because alternate diagnoses not incorporated in the models were considered. © RSNA, 2016 Online supplemental material is available for this article.

Maternal and neonatal outcomes in pregnancies following colorectal cancer.

BACKGROUND: The risks of adverse obstetric outcomes among young women survivors of colorectal cancer (CRC) are uncertain. METHODS: This Western Australian, whole-jurisdictional linked-data, retrospective cohort study compared maternal and neonatal outcomes of first postcancer pregnancies among women CRC survivors against randomly selected pregnancies of women with no cancer history. Logistic regression models were used to investigate a range of adverse outcomes independently associated with CRC and its surgical and adjunctive treatments. RESULTS: Among 627,762 deliveries during the study period (1983-2007), 232 were first pregnancies following CRC. Whether following laparoscopic or open cancer surgery, these pregnancies were independently associated with a significantly increased risk of antepartum hemorrhage [odds ratios (ORs): 1.25; 2.13 for the respective procedures], postpartum hemorrhage (ORs: 1.61; 3.31), Cesarean delivery (ORs: 2.42; 4.24), infant low Apgar score (ORs: 1.32; 2.64), need for neonatal resuscitation (ORs: 1.49; 3.20), and special care admission (ORs: 1.42; 2.87). A history of open (but not laparoscopic) cancer surgery was associated with increased risk of gastrointestinal obstruction during pregnancy (OR 1.17) and prolonged postpartum hospitalization (OR 3.11). Neither was significantly associated with perinatal death. Among women with previous CRC, rectal (versus colonic) malignancy was independently associated with a significantly higher risk of overall maternal and neonatal adverse outcomes (ORs: 3.73 and 2.73, respectively), as was radiotherapy (ORs: 4.24 and 2.81, respectively). Chemotherapy was independently associated with a marginally but significantly higher risk of overall maternal but not neonatal outcomes (ORs: 1.11; 0.98). Open versus laparoscopic cancer surgery was associated with a significantly higher risk of antepartum and postpartum hemorrhage, low Apgar score, need for neonatal resuscitation, and neonatal special care admission. CONCLUSIONS: Previous CRCs, particularly rectal and radiation-treated tumors, appear to confer an increased likelihood of adverse outcomes in subsequent pregnancies. Laparoscopic technique for CRC surgery may reduce adverse gestational outcomes.

The myth of informed consent in rectal cancer surgery: what do patients retain?

BACKGROUND: Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process. OBJECTIVES: The aims of this study were to describe the decisional needs of adult patients with rectal cancer when deciding on the surgical treatment of their disease and to identify gaps in patients' recollection of the informed consent discussion. DESIGN: Face-to-face interviews were conducted with the use of a questionnaire based on the validated Ottawa Decision Support Framework Needs Assessment. SETTING: This study was performed at a university-based academic Cancer Assessment Center, in Ottawa, Ontario, Canada. PATIENTS: Adult patients with rectal cancer treated with low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES: The primary outcomes measured were patients' knowledge and understanding of decision and their decisional needs. RESULTS: Thirty patients were interviewed between November 2009 and July 2010. Eighty percent were male, with a median age of 65. None of the patients perceived having a choice of surgical options. When questioned about the main outcomes of rectal cancer surgery, 47% could not recall a preoperative discussion of risks to bowel function, 47% could not recall a preoperative discussion of risks to sexual function, and 57% could not recall a preoperative discussion of risks to urinary function. Patients would like information regarding functional outcomes, body image, and the immediate postoperative period. A minority of patients desire information regarding cure rate, need for a second surgery, or the ability of surgery to treat their symptoms. Patients would like information that is portable and trusted by their health care team that they can review at their own time. LIMITATIONS: To avoid introducing decisional conflict before surgery, patients were interviewed at the first postoperative visit. Preoperative informed consent discussions were not standardized. CONCLUSION: Despite a comprehensive educational oncology pathway, patients retain little of the informed consent discussion. This study highlights the dichotomy between the outcomes that surgeons and patients value most. The results of this study will guide future efforts to improve informed consent.

Assessing the impact of a 2-day laparoscopic intestinal workshop.

BACKGROUND: Surgical educators have responded to the demand for increased skills in minimally invasive surgery by offering short technique-focused workshops at academic centres. The purpose of this study was to determine the impact of a comprehensive laparoscopic intestinal workshop for the adoption of laparoscopic colonic surgery. METHODS: A 2-day comprehensive laparoscopic intestinal surgery workshop included didactic teaching and supervised hands-on practice of numerous laparoscopic colon resections on a cadaveric model. Participants completed pre-, post- and 6-month postcourse questionnaires. RESULTS: The participants (n = 39) had been in practice for a mean of 10 (interquartile range 3-18) years. Fifty-one percent (n = 20) were already performing laparoscopic colectomies as part of their practices prior to the course. Regardless of whether they were performing laparoscopic colectomies prior to the course or not, attending the 2-day workshop improved their self-assessed preparedness to perform laparoscopic colectomies. Six months after the intestinal workshop, 10 of 16 respondents who were not performing laparoscopic colectomies prior to the course had performed at least 1 since the course. Seven of these individuals had a preceptor for their first case. Reasons cited for not performing a laparoscopic colectomy since the workshop included perceived inadequate surgical skill set, a lack of preceptor and the lack of an appropriate patient. CONCLUSION: A comprehensive laparoscopic intestinal workshop contributed to the perceived acquisition of advanced laparoscopic surgical skills. Local laparoscopic preceptorship was an important adjunct to the workshop for the incorporation of laparoscopic colorectal surgery into practice.

Laparoscopic colostomy reversal after a Hartmann procedure: a prospective series, literature review and an argument against laparotomy as the primary approach.

BACKGROUND: Open restoration of bowel continuity after a Hartmann procedure has been associated with significant morbidity, including anastomotic leak, incisional hernia, wound infections and inability to re-establish intestinal continuity. Few studies have examined the role of laparoscopy in performing a Hartmann reversal. The aim of this study was to review our laparoscopic Hartmann reversal (LHR) experience with an emphasis on intra- and postoperative adverse events. METHODS: A prospectively collected laparoscopic colorectal database involving 3 surgeons in 4 academic centres between 1991 and 2008 was reviewed. Factors evaluated were patient demographics, diagnosis, duration of surgery, intra- and postoperative complications, recovery of bowel function and length of stay in hospital. RESULTS: Twenty-eight consecutive patients (13 men, 15 women) with a mean age of 61.1 (standard deviation [SD] 15.3) years and a mean weight of 72.3 (SD 20.1) kg underwent LHR. The diagnosis at initial surgery was complicated diverticulitis in 19 patients (67.9%), cancer in 6 patients (21.4%) and "other" in 3 patients (10.7%). The median duration of surgery was 166.2 (SD 74.4) minutes. There were no conversions. There was 1 major intraoperative complication (bleeding; 3.6%). There were 3 postoperative complications (10.7%): 1 abscess, 1 prolonged ileus and 1 wound hematoma. Only 1 patient with an abscess required readmission. There were no observed clinical anastomotic leaks. All patients underwent successful reanastomosis. The median time to return of bowel function was 4 (interquartile range [IQR] 3-4) days. The median length of stay in hospital was 5 (IQR 3-6) days. There was no mortality. CONCLUSION: Laparoscopic colostomy reversal after a Hartmann procedure is safe and feasible in experienced hands. It is associated with low morbidity, quick return of bowel function and short stay in hospital.

Resident training in minimally invasive surgery: a survey of Canadian department and division chairs.

BACKGROUND: This study aimed to seek the opinions of academic surgical chairs on minimally invasive surgery (MIS) education for general surgery residents and to identify perceived gaps and trends in educational strategies. METHODS: A national survey on attitudes toward MIS was sent to the chairs of departments of surgery and divisions of general surgery across the 16 Canadian academic centers. The survey contained 34 questions consisting of Likert scales, single answers, and multiple-choice questions. Nonresponders were contacted directly. At the time of the survey, two department chair positions were vacant. RESULTS: The response rate was 87% (26/30). The majority of the centers used early operating room exposure to basic MIS cases (92%) and animal labs (85%). Two-thirds of the institutions used early operating room exposure to advanced MIS cases (69%) and didactic lectures (65%). Half of the academic centers used MIS video (54%) and the laparoscopic virtual reality simulator (54%). The least used method was computer software (19%). The surgical division and department chairs believed the most effective teaching method was early operating room exposure to basic MIS cases (100%), followed by the laparoscopic virtual reality simulator (91%) and animal labs (88%). Computer software was considered 42% useful, and the least useful method was didactic lectures (16%). In the next 5 years, 62% of academic centers plan to add laparoscopic virtual reality simulators to their MIS curriculum. CONCLUSION: The chairs' opinion on the most effective MIS teaching method for residents is basic MIS cases followed by laparoscopic virtual reality simulators. The majority of academic institutions plan to add laparoscopic virtual reality simulators to the curriculum in the next 5 years.

Laparoscopic colectomy for complex diverticular disease: a justifiable choice?

BACKGROUND: Surgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease. METHODS: Consecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated. RESULTS: A total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; p = 0.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; p < 0.0001) and surgical (28 vs. 14%; p = 0.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; p = 0.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1 day. CONCLUSIONS: The laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.

Hand assisted laparoscopic surgery versus conventional laparoscopy for colorectal surgery.

BACKGROUND: Laparoscopic surgery for colon disease has been shown to have advantages over the open approach in the perioperative period in terms of shorter hospital stay, decreased analgesic use and a more rapid return of bowel function but provides these benefits at the expense of increased technical difficulty and operative time. Hand assisted surgery which a is a hybrid of open surgery and laparoscopic surgery may offer patients the perioperative advantages of minimally invasive surgery without the technical difficulty and increased operative time associated with the conventional laparoscopic approach. This review compares the benefits and harms of laparoscopic and hand assisted laparoscopic surgery for colon disease. OBJECTIVES: To estimate the perioperative outcomes of hand assisted laparoscopic surgery compared to conventional laparoscopic surgery in adult patients requiring colorectal resections. SEARCH STRATEGY: We searched EMBASE (1980- Feb 2010), Medline (1966- Feb 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, 2010 issue 1), references of included studies, relevant review articles and conference abstracts. SELECTION CRITERIA: Randomised controlled trials (RCTs) in which adult patients were allocated to either receive hand-assisted laparoscopic surgery or conventional laparoscopic colorectal resection for benign or malignant colorectal disease. Studies were not restricted by language of publication. DATA COLLECTION AND ANALYSIS: Reports of potentially relevant articles were retrieved in full text, and two reviewers independently assessed the eligibility of these studies. Data abstraction was performed independently by two reviewers. Meta-analysis of perioperative outcome measures was carried out using a random effects model.  MAIN RESULTS: Three randomised controlled studies met the inclusion criteria (n=189). One study focused exclusively on malignant pathology, the second study focused mostly on benign pathology and the third trial had a mixed variety of pathology with approximately a third representing malignant pathology. Conversion rates were significantly decreased in patients undergoing hand assisted surgery but there was no statistically significant difference in operative time or complication rates when comparing hand assisted surgery to conventional laparoscopy.  All studies were associated with methodological limitations.    AUTHORS' CONCLUSIONS: Despite the limited number of trials performed, meta-analysis demonstrated a statistically significant decrease in conversion rates among the hand assisted group. There was no difference in operating time or perioperative complication rates.  Additional adequately powered and methodologically sound trials are needed to determine if there is a clinically important difference in perioperative outcomes.  Due to significant costs associated with the use of hand-assist devices, economic analyses are also warranted. 

Randomised, double-blinded, placebo-controlled trial to investigate the role of laparoscopic transversus abdominis plane block in gastric bypass surgery: a study protocol.

INTRODUCTION: Evaluating the efficacy of a laparoscopically guided, surgical transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing analgesic consumption while improving functional outcomes in patients undergoing laparoscopic bariatric surgery. METHODS: 150 patients Living with obesity undergoing elective laparoscopic Roux-En-Y gastric bypass for obesity will be recruited to this double-blinded, placebo-controlled randomised controlled trial from a Bariatric Centre of Excellence over a period of 6 months. Patients will be electronically randomised on a 1:1 basis to either an intervention or placebo group. Those on the intervention arm will receive a total of 60 mL 0.25% ropivacaine, divided into four injections: two for TAP and two for RS block under laparoscopic visualisation. The placebo arm will receive normal saline in the same manner. A standardised surgical and anaesthetic protocol will be followed, with care in adherence to the Enhanced Recovery after Bariatric Surgery guidelines. ANALYSIS: Demographic information and relevant medical history will be collected from the 150 patients enrolled in the study. Our primary efficacy endpoint is cumulative postoperative narcotic use. Secondary outcomes are peak expiratory flow, postoperative pain score and the 6 min walk test. Quality of recovery (QoR) will be assessed using a validated questionnaire (QoR-40). Statistical analysis will be conducted to assess differences within and between the two groups. The repeated measures will be analysed by a mixed modelling approach and results reported through publication. ETHICS AND DISSEMINATION: Ethics approval was obtained (20170749-01H) through our institutional research ethics board (Ottawa Health Science Network Research Ethics Board) and the study results, regardless of the outcome, will be reported in a manuscript submitted for a medical/surgical journal. TRIAL REGISTRATION NUMBER: Pre-results NCT03367728.

Laparoscopic colon surgery: does operative time matter?

PURPOSE: The purpose was to determine if the perioperative benefits associated with laparoscopic colectomies are maintained as operative time increases. METHODS: A retrospective review was performed of a database that was prospectively collected from April 1991 to May 2005. Since operative time distributions were different, patients were divided into three groups: laparoscopic right colectomy or ileocecal resection, sigmoid resection, and total abdominal colectomy. The following outcomes were assessed: intraoperative and postoperative complications, days to surgical diet, length of stay, 30-day mortality, and the presence of a learning curve. RESULTS: Following exclusions, there were 231 right colon and ileocecal resections, 210 sigmoid colectomies, and 46 total abdominal colectomies. With increasing operative time in both right/ileocecal and sigmoid resections, logistic regression demonstrated no significant association between intraoperative and postoperative complications, days to surgical diet, or length of stay. Weight was significantly correlated with increasing operative time in the right/ileocecal and sigmoid resection groups. In the total abdominal colectomy group, significant relationships between increased operative time and postoperative complications (P = 0.04), days to surgical diet (P = 0.02), and hospital stay (P = 0.03) were found. An operative time cut-point was determined in the total abdominal colectomy group. Patients with operative times >270 minutes were more likely to have postoperative complications (P = 0.024), longer ileus (five vs. three median days to surgical diet, P = 0.003), and longer length of stay (seven vs. five days, P = 0.04). This increased risk remained significant after adjusting for weight and diagnosis. No significant learning curve was identified. CONCLUSION: Increasing operative time does not appear to adversely affect perioperative outcomes in segmental colectomies. Total abdominal colectomies lasting more than 270 minutes were associated with increased postoperative complications, days to surgical diet, and length of stay.

Impact of incision length on the short-term outcomes of laparoscopic colorectal surgery.

BACKGROUND: The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections. METHODS: Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test. RESULTS: A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4-6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications. CONCLUSIONS: Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.

Does experience with laparoscopic colorectal surgery influence intraoperative outcomes?

BACKGROUND: This study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes. METHODS: Consecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared. RESULTS: A total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (n=526, 53%), and most frequently consisted of segmental colonic resections (n=718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68 kg, p=0.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, p=0.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39-8.35, p=0.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (p=0.025), and on patients who had a higher rate of previous intra-abdominal surgery (p<0.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (p=0.54) and conversion to open surgery (p=0.40). CONCLUSIONS: The majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion.

The adoption of laparoscopic colorectal surgery: a national survey of general surgeons.

BACKGROUND: Laparoscopic surgery may become the standard of care for the treatment of colorectal disease. Little is known regarding North American patterns of practice or the limiting factors and strategies for adoption among surgeons. METHODS: We sent a 28-item questionnaire to all general surgeon members of the Royal College of Physicians and Surgeons of Canada. We derived descriptive and correlative information using chi(2), Wilcoxon rank sum and Student t tests and multivariate logistic regression. RESULTS: The return rate was 55% (694/1266). A total of 67% (462/694; 95% confidence interval 63%-70%) of respondents perform colorectal surgery. Of these, 54% perform laparoscopic colorectal surgery. Multivariate logistic regression identified 5 factors related to performing laparoscopic colorectal surgery: fewer years in practice (p < 0.001), male sex (p = 0.015), practising in the province of Quebec (p = 0.005), university-hospital affiliation (p = 0.034) and minimally invasive surgery fellowship training (p = 0.023). Lack of adequate operating time and formal training were the main reasons cited by surgeons not offering laparoscopic colon resections. Most surgeons (67%) felt that site visits from a minimally invasive surgeon would represent the most effective training method for acquiring advanced laparoscopic skills. CONCLUSION: About half of Canadian general surgeons offer laparoscopic colorectal resections. Recent graduation, male sex, practice location, university-hospital affiliation and minimally invasive surgery training are significant predictors for offering a laparoscopic approach. Lack of operative time and formal training are the main barriers to adoption of the technique. Site visits by trained laparoscopic surgeons is the preferred method of acquiring advanced skills.

Neoadjuvant therapy and anastomotic leak after tumor-specific mesorectal excision for rectal cancer.

PURPOSE: This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery. METHODS: A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model. RESULTS: A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (

Laparoscopic repair of paraesophageal hernias: a Canadian experience.

BACKGROUND: The surgical approach to paraesophageal hernias (PEH) has changed with the advent of laparoscopic techniques. Variation in both perioperative outcomes and hernia recurrence rates are reported in the literature. We sought to evaluate the short- and intermediate-term outcomes with laparoscopic PEH repair. METHODS: We performed a retrospective review of patients having laparoscopic repair of PEH between June 1998 and September 2002. We included patients with more than 120 days of follow-up. RESULTS: A total of 58 patients with a mean age of 60.4 (standard deviation [SD] 15.0) years had a laparoscopic procedure to repair a primary PEH, as well as adequate follow-up, during the study period. The types of PEH included type II (n = 13), III (n = 44) and IV (n = 1). The most common symptoms were epigastric pain (57%), dysphagia (40%), heartburn (31%) and vomiting (28%). Associated procedures included 56 (96%) Nissen fundoplications and 2 (4%) gastropexies. We closed all crural defects either with or without pledgets, and 2 patients required the use of mesh. There was 1 conversion to open surgery owing to intraoperative bleeding secondary to a consumptive coagulopathy; we observed no other major intraoperative emergencies. Minor or major complications occurred in 15 patients (26%). Late postoperative complications included 1 umbilical hernia. The mean length of stay in hospital was 3.8 (SD 2.5) days. After surgery, 19 patients were completely asymptomatic, and the majority of the remaining patients (83%) described marked symptom improvement. Upper gastrointestinal series performed in symptomatic patients in the postoperative setting identified 5 recurrent paraesophageal hernias (8.6%) and 5 small sliding hernias (9%). CONCLUSION: Laparoscopic repair of PEH is associated with improved long-term symptom relief, low morbidity and acceptable recurrence rates when performed in an experienced centre.

Staging and surgical approaches in gastric cancer: A systematic review.

BACKGROUND: Gastric adenocarcinoma accounted for 6.8% of new cancer cases and 8.8% of cancer deaths worldwide in 2012. Although resection is the cornerstone for cure, several aspects of surgical intervention remain controversial or sub-optimally applied at the population level. These include staging, extent of lymph node dissection (LND), optimal requirements of LN assessment, minimum resection margins, surgical technique (laparoscopic vs. open), relationship between surgical volumes and patient outcomes, and resection of stage IV gastric cancer. METHODS: A systematic review was conducted to inform surgical care. RESULTS: The evidence included in this systematic review consists of one guideline, seven systematic reviews and 48 primary studies. CONCLUSIONS: All patients should be discussed at a multidisciplinary team meeting and a staging CT of the chest and abdomen should always be performed. Diagnostic laparoscopy should be performed in patients at risk for stage IV disease. A D2 LND is preferred for curative-intent resection in advanced non-metastatic gastric cancer. At least 16 LNs should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an RO resection margin. In the metastatic setting, surgery should only be considered for palliation of symptoms. Patients should be referred to higher volume centres, and those with adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as open resections.

Are transverse colon cancers suitable for laparoscopic resection?

BACKGROUND: The large randomized trials reporting on laparoscopic versus open colon surgery for cancer have all excluded patients with transverse colon cancer lesions. This study was undertaken to review our experience with surgery for curable transverse colon cancer. METHODS: A database of 938 laparoscopic colon resections performed between April 1991 and September 2004 was reviewed. Of 514 procedures for cancer, stage IV disease, mid to low rectal cancers, and total colectomies were excluded. On an intent-to-treat basis, outcomes of surgery for transverse colon lesions (TC) were compared with outcomes of segmental colon resections for other lesions (OC). RESULTS: A total of 22 TC were resected compared with 285 OC. Patients with TC were similar to patients with OC in age, gender, weight, and body mass index (BMI). Cancer stage was equivalent between patients with TC (9 Stage I, 7 Stage II, 6 Stage III) and OC (66 Stage I, 126 Stage II, 93 Stage III, p = 0.170) as was tumor size. Patients with TC underwent 9 transverse colectomies, 12 extended right hemicolectomies, and 1 extended left hemicolectomy. Patients with OC underwent 126 right hemicolectomies, 24 left hemicolectomies, and 135 sigmoid colectomies or anterior resections. There were no differences in conversion rate (18.2% vs. 13.3%, p = 0.752) or in intraoperative (9% vs. 8%, p = 0.814) or postoperative (41% vs. 30%, p = 0.418) complications. Operating time was longer with TC (209 +/- 63 min vs. 176 +/- 60 min, p = 0.042) and lymph node harvest was higher (15.3 +/- 11.6 vs. 10.8 +/- 7.6, p = 0.011). At a median followup of 17.2 months and 17.1 months, respectively, there were two (9%) recurrences after resection of TC and 17 (6%) recurrences after resection of OC. CONCLUSIONS: Laparoscopic resection of transverse colon cancers is technically feasible and not associated with a significantly higher rate of complications or conversions or with impaired oncologic outcomes compared with patients having segmental laparoscopic resections for other colon cancers. Operating time is longer.