Reversal of Hartmann's procedure utilizing single-port laparoscopy: an attractive alternative to laparotomy.

BACKGROUND: Complications after restoration of intestinal continuity (RIC) following Hartmann's procedure occur frequently and are often serious. These complications result in a reported morbidity of 4-30 % and a reported mortality of 10-14 %. Reducing the amount of surgical trauma accompanying abdominal access seems an attractive tool to reduce perioperative morbidity. This possibility is offered by single-port Hartmann's reversal (SPHR) through the colostomy site. METHODS: The purpose of the present prospective study was to compare outcome of SPHR to a retrospectively collected historical control group of conventional open Hartmann's reversal (OHR). All patients undergoing RIC between January 1, 2009, and January 1, 2014, were included in the present study. Operation time, morbidity and hospital stay were assessed. Postoperative surgical results of SPHR and OHR were the main outcome of the study. RESULTS: During the study period, 41 patients (M/F = 23:18; median age 58 (26-85) years) were included in the present study. Sixteen patients underwent OHR; 25 patients underwent SPHR. No mortality was observed in the present series. Median operation time was similar between groups [184 (29-377) vs. 153.5 (73-332) min]. Hospital stay was significantly shorter in the SPHR group [16 (4-74) vs. 4 (1-34) days, p < 0.05]. The number of complications was significantly lower in the SPHR group (33 vs. 10, p < 0.05); furthermore, significantly less patients had severe complications (Clavien-Dindo III or higher) in the SPHR group (7/33 vs. 1/10). Less wound-related complications occurred in the SPHR group (12 vs. 5, p < 0.05). CONCLUSION: This study confirms recent findings in the literature regarding the safety and feasibility of SPHR. SPHR seems to be an attractive alternative to OHR.

Transanal minimally invasive surgery: initial experience and short-term functional results.

BACKGROUND: Currently, the preferred method for local excision of rectal polyps is transanal endoscopic microsurgery, avoiding rectal resection. Transanal minimally invasive surgery is a relatively new technique using a disposable port in combination with conventional laparoscopic instruments. This method is less expensive as compared with transanal endoscopic microsurgery, relatively easy to learn, and available. Despite wide adoption of transanal minimally invasive surgery, to date only a few series on the implementation and use of this technique are reported, and detailed information on the effect of transanal minimally invasive surgery on fecal continence is not available. OBJECTIVE: The purpose of this work was to prospectively assess the functional outcome after transanal minimally invasive surgery using the Fecal Incontinence Severity Index preoperatively and postoperatively. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a large teaching hospital. PATIENTS: Patients included those who underwent transanal minimally invasive surgery between October 2011 and September 2013. INTERVENTIONS: Transanal minimally invasive surgery was studied. MAIN OUTCOME MEASURES: We measured postoperative surgical and functional results. RESULTS: A total of 37 patients underwent transanal minimally invasive surgery during our study period. Short-term morbidity rate was 14%, and positive resection margins were reported in 6 cases (16%); in 1 of these patients, a local recurrence was observed. Overall, there was a significant decline in preoperative and postoperative Fecal Incontinence Severity Index scores (p = 0.02), indicating an improvement in anorectal function after transanal minimally invasive surgery for patients with impaired preoperative continence. Seventeen patients (49%) had impaired continence before transanal minimally invasive surgery (mean Fecal Incontinence Severity Index score = 21). Continence improved in 15 (88%) of these patients after surgery; no change was observed in 1 patient (6%), and continence further decreased in another. In addition, 18 patients (51%) had normal preoperative continence (Fecal Incontinence Severity Index score = 0), of which 83% had no change in functionality, and continence decreased in 3. LIMITATIONS: No quality of life was measured. CONCLUSIONS: Short-term functional results of transanal minimally invasive surgery for rectal polyps are excellent and comparable to functional results using the dedicated transanal endoscopic microsurgery equipment. More research on outcome after transanal minimally invasive surgery is needed to assess morbidity rates and oncologic clearance.

A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study).

BACKGROUND: The present developments in colon surgery are characterized by two innovations: the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery (ERAS) recovery program. The Tapas-study was conceived to determine which of the three treatment programs: open conventional surgery, open 'ERAS' surgery or laparoscopic 'ERAS' surgery for patients with colon carcinomas is most cost minimizing? METHOD/DESIGN: The Tapas-study is a three-arm multicenter prospective cohort study. All patients with colon carcinoma, eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included. This design produces three cohorts: Conventional open surgery is the control exposure (cohort 1). Open surgery with ERAS recovery (cohort 2) and laparoscopic surgery with ERAS recovery (cohort 3) are the alternative exposures. Three separate time periods are used in order to prevent attrition bias. Primary outcome parameters are the two main cost factors: direct medical costs (real cost price calculation) and the indirect non medical costs (friction method). Secondary outcome parameters are mortality, complications, surgical-oncological resection margins, hospital stay, readmission rates, time back to work/recovery, health status and quality of life. Based on an estimated difference in direct medical costs (highest cost factor) of 38% between open and laparoscopic surgery (alfa = 0.01, beta = 0.05), a group size of 3 x 40 = 120 patients is calculated. DISCUSSION: The Tapas-study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma, which may serve as a guideline for choice of treatment and investment strategies in hospitals. TRIAL REGISTRATION: ISRCTN44649165.

The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037).

BACKGROUND: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). METHODS/DESIGN: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs. DISCUSSION: The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis. TRIAL REGISTRATION: Nederlands Trial Register NTR2037.

Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial).

BACKGROUND: With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction. The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs. METHODS/DESIGN: The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007. DISCUSSION: The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease. TRIAL REGISTRATION: Nederlands Trial Register NTR1150.

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

BACKGROUND: The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure-signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)-frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure. METHODS: Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons. RESULTS: No difference in major complication rate was seen (2.8 vs. 2.3 %, p = 0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien-Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p < 0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36-110). CONCLUSIONS: Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

Early Postoperative Progression to Solid Foods Is Safe After Roux-en-Y Gastric Bypass.

BACKGROUND: Even though admission time is reduced with the implementation of various enhanced recovery protocols, many clinics still instruct patients after weight loss surgery to maintain a fluid or minced-food diet for at least 2 weeks postoperatively. We reasoned that with adequate preoperative instructions, including adequate chewing of all foods, early progression to solid foods would not increase the risk of (gastro)enterostomy leakage. METHODS: In December 2010, a new dietary protocol was implemented for all patients undergoing a Roux-en-Y gastric bypass, allowing progression to solid foods from 12 h postprocedure onwards. All patients received thorough preoperative eating instructions and eating awareness counselling from a qualified dietician and psychologist. A retrospective study was performed of 936 patients who underwent a primary or redo laparoscopic Roux-en-Y gastric bypass between January 2011 and June 2014 in our hospital. All 30-day complications, readmissions and reoperations were noted. RESULTS: No 30-day loss to follow-up occurred. Overall 30-day complication rate was 9.4%, with gastrointestinal leakage occurring in only 0.6%. A low threshold for readmission was maintained due to the short mean admission time of 1.87 days. Readmission rate was 4.8%--mainly for observation of postoperative pain--and 1.8% of our patients required reoperation within 30 days. Mortality was 0.1%. Our results are comparable to results published by other Dutch centres advocating conventional diets, showing no increase in leakage or other complications. CONCLUSIONS: We conclude that early progression to solid foods after Roux-en-Y gastric bypass surgery is a feasible alternative as no increase in complications is observed.

[Subcutaneous emphysema as the initial symptom of perforated diverticulitis]. / Subcutaan emfyseem als eerste symptoom van een geperforeerde diverticulitis.

A 76-year-old woman with no medical history apart from hypertension was admitted to the department of Internal Medicine with rectal bleeding. A few days later she complained of severe pain in her left leg. On physical examination the leg was swollen, shiny and extremely painful to the touch. Later she developed subcutaneous emphysema of the upper leg. A CT-scan revealed perforated sigmoid diverticulitis and extensive subcutaneous and intramuscular emphysema. During surgery, a double-barrelled colostomy was raised on the transverse colon. All subcutaneous areas with emphysema were drained. During a second operation, a Hartmann resection was performed, with a distal mucous fistula on the descending colon. A few days later she died as a result of septicaemia. Subcutaneous emphysema is a rare complication of perforated diverticulitis. A lack of prospective studies on diverticulitis hampers a rational approach to this common condition in daily practice.

Selective bowel decontamination in elective liver transplantation: no improvement in endotoxaemia, initial graft function and post-operative morbidity.

Peri-operative endotoxaemia during liver transplantation has been linked to compromised graft function and infection. Selective decontamination of the digestive tract (SDD) could prevent endotoxaemia by eradicating Gram-negative bacteria from the intestine. In a randomized placebo controlled study we investigated the effects of endotoxaemia and the efficacy of SDD to prevent its occurrence. Thirty-one patients undergoing elective orthotopic liver transplantation received either SDD ( n=15) or placebo ( n=16), which was started at least 7 days before transplantation. Endotoxin levels were measured in blood peroperatively. Patients were scored daily for signs of liver dysfunction and infection. Endotoxaemia was neither associated with initial poor function nor any routine liver function test. Infections were more prominent in patients without endotoxaemia. SDD did not prevent endotoxaemia. Endotoxaemia does not affect post-operative graft function or the incidence of post-operative infections. SDD cannot prevent peri-operative endotoxaemia. Translocation of endotoxin may not be relevant in liver transplantation.

Selective decontamination of the digestive tract to prevent postoperative infection: a randomized placebo-controlled trial in liver transplant patients.

OBJECTIVE: To determine the efficacy of selective decontamination of the digestive tract (SDD) in patients undergoing elective transplantation of the liver. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Two academic teaching hospitals. PATIENTS: Adult patients undergoing elective liver transplantation: 26 patients receiving SDD and 29 patients receiving a placebo. INTERVENTIONS: Patients undergoing SDD were administered 400 mg of norfloxacin once daily as soon as they were accepted for transplantation. Postoperative treatment for this group consisted of 2 mg of colistin, 1.8 mg of tobramycin, and 10 mg of amphotericin B, four times daily, combined with an oral paste containing a 2% solution of the same drugs until postoperative day 30. Prophylactic intravenous administration of antibiotics was not part of the SDD regimen in this study. Control patients were given a similar regimen with placebo drugs. MEASUREMENTS: The mean number of postoperative bacterial and fungal infections in the first 30 days after transplantation was the primary efficacy end point. Days on a ventilator, days spent in the intensive care unit, and medical costs were registered as secondary outcome variables. MAIN RESULTS: Of the 26 patients undergoing SDD, 22 (84.5%) developed an infection in the postoperative study period; in the placebo group (n = 29), these numbers were not significantly different (25 patients, 86%). The mean number of postoperative infectious episodes per patient was also not significantly different: 1.77 (SDD) vs. 1.93 (placebo). Infections involving Gram-negative aerobic bacteria and Candida species were significantly less frequent in patients receiving SDD (p <.001 and p <.05). Total costs were higher in the group receiving SDD. CONCLUSIONS: Selective decontamination of the digestive tract does not prevent infection in patients undergoing elective liver transplantation and increases the cost of their care. It does, however, affect the type of infection. Infections with Gram-negative bacilli and with Candida species are replaced by infections with Gram-positive cocci.