Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP. World J Surg. 2012;36:2488-2496. [PMID: 22736343 DOI: 10.1007/s00268-012-1694-x]

Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis

INTRODUCTION

While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes.

METHODS

Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay.

RESULTS

The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference.

CONCLUSIONS

There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.

Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of the American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION

Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication.

RESULTS

Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16).

DISCUSSION

Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.

Short-term outcomes following total colectomy for inflammatory bowel disease in Denmark after implementation of laparoscopy: a nationwide population-based study

AIM

A laparoscopic approach to total colectomy (TC) for inflammatory bowel disease (IBD) is being increasingly used, but data on its comparative benefits over open TC are conflicting. The aim of this study was to examine 90-day outcomes following laparoscopic and open TC for IBD in a nationwide cohort after the introduction of laparoscopy.

METHOD

IBD patients undergoing TC in Denmark from 2005 to 2017 were identified from the Danish National Patient Registry. We used Kaplan-Meier methodology to estimate mortality and Cox regression analysis to estimate adjusted mortality rate ratios (aMRRs) and adjusted hazard ratios (aHRs) of reoperation, readmission and intensive care unit (ICU) transfer, comparing patients undergoing laparoscopic versus open TC.

RESULTS

We identified 1095 patients undergoing laparoscopic TC and 1523 patients undergoing open TC. Following emergency TC, 90-day mortality was 2.8% (1.6%-4.9%) after laparoscopic TC and 9.1% (7.0%-11.8%) after open TC. Ninety-day mortality was 0.9% (0.3%-2.5%) after laparoscopic TC and 2.6% (1.5%-4.3%) after open elective TC. The aMRRs associated with laparoscopic TC were 0.45 (95% CI 0.25-0.80) in emergency cases and 0.29 (95% CI 0.10-0.86) in elective cases. Risks of readmission were comparable following laparoscopic versus open TC, both in emergency [aHR = 0.93 (95% CI 0.76-1.15)] and elective [aHR = 0.83 (95% CI 0.68-1.02)] cases, while risks of ICU transfer and reoperation were lower following laparoscopic TC, both in emergency cases [aHR = 0.53 (95% CI 0.35-0.82) and aHR = 0.26 (95% CI 0.15-0.47)] and elective [aHR = 0.58 (95% CI 0.35-0.95) and aHR = 0.37 (95% CI 0.21-0.66)] cases.

CONCLUSION

The introduction of laparoscopic TC for IBD in Denmark was not associated with increased mortality or morbidity. In fact, laparoscopic TC for IBD may be associated with lower short-term mortality and morbidity compared with open TC.

Redo laparoscopic colorectal resection: a retrospective analysis with propensity score matching

PURPOSE

Reports of redo laparoscopic colorectal resection (Re-LCRR) are scarce. In order to evaluate the safety and short-term outcomes of Re-LCRR, we performed a matched case-control analysis of patients who underwent this procedure for colorectal cancer.

METHOD

This was a retrospective, monocentric study that included patients who underwent Re-LCRR for colorectal cancer between January 2011 and December 2019 at our institution. The patients were compared to a 2:1 matched sample. Matching was conducted based on age, sex, BMI, surgical procedure, and clinical stage.

RESULT

Twenty-nine patients underwent Re-LCRR (RCRR group) and were compared to 58 patients selected by matching who underwent LCRR as primary resection (PCRR group). The median of age of the 29 patients of RCRR group was 75 (IQR 56-81) years and the RCRR group included 14 males. The median operative time of the RCRR group was 167 (IQR 126-232) minutes, and the median intraoperative blood loss was 5 (IQR 2-35) ml. In the RCRR group, there were no cases that required conversion to laparotomy. The short-term outcomes of the two groups did not differ to a statistical extent with respect to operative time (p = 0.415), intraoperative blood loss (p = 0.971), rate of conversion to laparotomy (p = 0.477), comorbidity (p = 0.215), and postoperative hospital stay (p = 0.809). No patients in either group experienced postoperative anastomotic leakage or required re-operation due to postoperative complications, and there was no procedure-related death. However, in terms of oncological factors, although there was no difference in the number of cases with a positive radical margin between the two groups (p = 1.000), the number of harvested lymph nodes in the RCRR group was significantly lower than that in the PCRR group (p = 0.015) and the RCRR group included 10 cases with less than 12 harvested lymph nodes.

CONCLUSION

Re-LCRR is associated with good short-term results and can be safely performed; however, the number of harvested lymph nodes is significantly reduced in comparison to primary resection cases, and further studies are needed to evaluate its long-term prognosis.

Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting: A Systematic Review and Meta-analysis

Objective

This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome.

Background

In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear.

Methods

PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment.

Results

Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed 'good quality' in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35-0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43-0.65), wound infection (OR, 0.63; 95% CI, 0.45-0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18-0.77), ileus (OR, 0.68; 95% CI 0.51-0.91), pulmonary (OR, 0.43; 95% CI, 0.24-0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35-0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data.

Conclusions

The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account.

Improved outcomes using laparoscopy for emergency colectomy after mitigating bias by negative control exposure analysis

BACKGROUND

Laparoscopy is superior to open surgery for elective colectomy, but its role in emergency colectomy remains unclear. Previous studies were small and limited by confounding because surgeons may have selected lower-risk patients for laparoscopy. We therefore studied the effect of attempting laparoscopy for emergency colectomies while adjusting for confounding using multiple techniques in a large, nationwide registry.

METHODS

Using National Surgical Quality Improvement Program data, we identified emergency colectomy cases from 2014 to 2018. We first compared outcomes between patients who underwent laparoscopic versus open surgery, while adjusting for baseline variables using both propensity scores and regression. Next, we performed a negative control exposure analysis. By assuming that the group that converted to open did not benefit from the attempt at laparoscopy, we used the observed benefit to bound the effect of unmeasured confounding.

RESULTS

Of 21,453 patients meeting criteria, 3,867 underwent laparoscopy, of which 1,375 converted to open. In both inverse probability of treatment weighting and regression analyses, attempting laparoscopy was associated with improved 30-day mortality, overall morbidity, anastomotic leak, surgical site infection, postoperative septic shock, and length of hospital stay compared with open surgery. These effects were consistent with the lower bounds computed from the converted group.

CONCLUSION

Laparoscopic surgery for colorectal emergencies appears to improve outcomes compared with open surgery. The benefit is observed even after adjusting for both measured and unmeasured confounding using multiple statistical approaches, thus suggesting a benefit not attributable to patient selection.

Cardiac risk stratification in emergency resection for colonic tumours

Background

Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

Methods

Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

Results

Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

Conclusion

This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

Laparoscopy improves failure to rescue compared to open surgery for emergent colectomy

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42-2.08), mortality (OR 1.72, 95% CI 1.44-2.07), and morbidity (OR 1.73, 95% CI 1.60-1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08-1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03-2.93), and septic shock (OR 2.34, 95% CI 1.97-2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p < 0.0001). This study demonstrates the safety and efficacy of the laparoscopic approach for emergent colectomy vs open surgery. Laparoscopy was associated with improved complications rates, mortality, and failure to rescue, indicating that it is a promising option to improve patient outcomes during emergent colectomy.

Role of Emergency Laparoscopic Colectomy for Colorectal Cancer: A Population-based Study in England

OBJECTIVE

To evaluate factors associated with the use of laparoscopic surgery and the associated postoperative outcomes for urgent or emergency resection of colorectal cancer in the English National Health Service.

SUMMARY OF BACKGROUND DATA

Laparoscopy is increasingly used for elective colorectal cancer surgery, but uptake has been limited in the emergency setting.

METHODS

Patients recorded in the National Bowel Cancer Audit who underwent urgent or emergency colorectal cancer resection between April 2010 and March 2016 were included. A multivariable multilevel logistic regression model was used to estimate odds ratios (ORs) of undergoing laparoscopic resection and postoperative outcome according to approach.

RESULTS

There were 15,516 patients included. Laparoscopy use doubled from 15.1% in 2010 to 30.2% in 2016. Laparoscopy was less common in patients with poorer physical status [American Society of Anaesthesiologists (ASA) 4/5 vs 1, OR 0.29 (95% confidence interval, 95% CI 0.23-0.37), P < 0.001] and more advanced T-stage [T4 vs T0-T2, OR 0.28 (0.23-0.34), P < 0.001] and M-stage [M1 vs M0, OR 0.85 (0.75-0.96), P < 0.001]. Age, socioeconomic deprivation, nodal stage, hospital volume, and a dedicated colorectal emergency service were not associated with laparoscopy. Laparoscopic patients had a shorter length of stay [median 8 days (interquartile range (IQR) 5 to 15) vs 12 (IQR 8 to 21), adjusted mean difference -3.67 (-4.60 to 2.74), P < 0.001], and lower 90-day mortality [8.1% vs 13.0%; adjusted OR 0.78 (0.66-0.91), P = 0.004] than patients undergoing open resection. There was no significant difference in rates of readmission or reoperation by approach.

CONCLUSION

The use of laparoscopic approach in the emergency resection of colorectal cancer is linked to a shorter length of hospital stay and reduced postoperative mortality.

Use of Maximum Surgical Order Schedule (MSBOS) among pediatric patients to optimize blood utilization

Background

Evaluating blood ordering and subsequent development of a blood ordering schedule can decrease over-ordering of blood among pediatric surgical patients. The objective is to assess our practice of blood utilization using various blood utilization indices and calculate the Maximal Surgical Blood Order Schedule (MSBOS). This is a cross-sectional study for 3 years that included patients (≤ 18 years old) who underwent major surgical procedures in the Philippine Children’s Medical Center. Data included type of surgery, age and sex, number of units crossmatched, number of units transfused, and timing of transfusion. Indices were calculated.

Results

This study revealed that the utilization rate was only 39.1% of blood among a total of 5314 cases done. The indices were analyzed according to different procedures among different age groups. Procedures for head and neck, colorectal, ostomy, solid tumors, genitourinary abnormalities, upper gastrointestinal, and appendectomy had CT (crossmatched to transfusion) ratio exceeding 2.0, indicating inappropriate blood ordering. Major abdominal, major thoracic, and hepatobiliary surgery all have CT ratio < 2.0. MSBOS was calculated, and a requisition of 1 unit of blood among patients undergoing these procedures is suggested.

Conclusions

The MSBOS is largely utilized to the adult population but its creation can also be utilized among pediatric patients. Our data shows that in majority of elective pediatric surgical procedures, routine crossmatch is not necessary which is proven by our high underutilization of requested blood products.

Safety and feasibility of repeat laparoscopic colorectal resection: a matched case-control study

BACKGROUND

Perioperative outcomes of repeat laparoscopic colorectal resection (LCRR) have not been extensively reported.

METHODS

Patients who underwent LCRR from 2010 to 2018 in an expert center were retrieved from a prospectively collected database and compared to 2:1 matched sample. Matching was based on demographics, surgical indication [colorectal cancer (CRC) or benign condition], and type of resection (right-sided resection or left-sided resection or proctectomy).

RESULTS

Twenty-three patients underwent repeat LCRR with a median time of 36 months between the primary and the repeat LCRR. They were 12 (52%) men with a mean age of 64.9 years (31-87) and a median BMI of 21.4 kg/m² (17.7-34). Indication for repeat LCRR was CRC, dysplasia, anastomotic stricture, and inflammatory bowel disease in 11 (48%), 5 (22%), 4 (17%), and 3 (13%) patients, respectively. A right-sided resection, a left-sided resection, and proctectomy were reported in 11 (48%), 8 (35%), and 4 (17%) patients, respectively. Median blood loss reached 211 mL (range 0-2000 mL). Thirteen (57%) patients required conversion to laparotomy including 12 for intense adhesions. The median length of hospital stay was 7.5 days (5-20). Two (9%) major complications (Clavien-Dindo ≥ 3) were reported: 1 (4%) anastomotic fistula and 1 (4%) postoperative hemorrhage, without mortality. Among patients who underwent repeat LCRR for CRC, histopathological examination showed R0 resection in all patients, with at least 12 lymph nodes harvested in ten (91%) patients. After matched case-control analysis that compared to primary LCRR, conversion rate (p = 0.03), operative time (p = 0.03), and intraoperative blood loss (p = 0.0016) were significantly increased in repeat LCRR, without impact on postoperative outcomes.

CONCLUSIONS

Repeat LCRR seems to be feasible and safe in expert hands without compromising the oncologic outcomes. Intense postoperative adhesions and misidentification of blood supply might lead to conversion to laparotomy. Real benefits of laparoscopic approach for repeat LCRR should be assessed in further studies.

Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery

The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74–2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30–2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Comparative analysis of outcomes after multiport and single-port laparoscopic colectomy in emergency situations: Is single-port laparoscopic colectomy safe and feasible?

BACKGROUND/OBJECTIVE

Although consensus has been reached on the superiority of laparoscopy for a majority of conditions underlying acute abdominal pain, the safety and feasibility of single-port laparoscopic colectomy (SPLC) in emergency situations have not been determined.

METHODS

A prospective electronic database of all emergency patients who underwent either multiport laparoscopic colectomy (MPLC) or SPLC between April 2006 and December 2014 was used to compare the surgical outcomes of these operative methods.

RESULTS

During the study period, 31 MPLCs and 76 SPLCs were performed. These two operative methods resulted in similar operating times, transfusion amounts, lengths of stay, postoperative complications, attainment of lymph nodes, and proximal and distal cut margins. However, the SPLC group had a shorter time to first flatus (2.8±1.9 days vs. 3.8±1.5 days, p=0.005), earlier reinitiation of free oral fluids (3.2±2.1 days vs. 4.4±1.8 days, p=0.002), and lesser requirement of narcotic analgesics (2.5±3.9 times vs. 4.7±4.8 times, p=0.017).

CONCLUSION

SPLC could be a safe and effective alternative to MPLC, even in emergency situations when performed by surgeons who have overcome the learning curve associated with single-port laparoscopic techniques. The tendency toward earlier returns to bowel function and decreased incidence of postoperative analgesic use would be potential benefits of SPLC in emergency situations.

Real-Time Measurement of the Tool-Tissue Interaction in Minimally Invasive Abdominal Surgery: The First Step to Developing the Next Generation of Smart Laparoscopic Instruments

Introduction Analysis of force application in laparoscopic surgery is critical to understanding the nature of the tool-tissue interaction. The aim of this study is to provide real-time data about manipulations to abdominal organs. Methods An instrumented short fenestrated grasper was used in an in vivo porcine model, measuring force at the grasper handle. Grasping force and duration over 5 small bowel manipulation tasks were analyzed. Forces required to retract gallbladder, bladder, small bowel, large bowel, and rectum were measured over 30 seconds. Four parameters were calculated-T(hold), the grasp time; T(close), time taken for the jaws to close; F(max), maximum force reached; and F(rms), root mean square force (representing the average force across the grasp time). Results Mean F(max) to manipulate the small bowel was 20.5 N (±7.2) and F(rms) was 13.7 N (±5.4). Mean T(close) was 0.52 seconds (±0.26) and T(hold) was 3.87 seconds (±1.5). In individual organs, mean F(max) was 49 N (±15) to manipulate the rectum and 59 N (±13.4) for the colon. The mean F(max) for bladder and gallbladder retraction was 28.8 N (±7.4) and 50.7 N (±3.8), respectively. All organs exhibited force relaxation, the F(rms) reduced to below 25 N for all organs except the small bowel, with a mean F(rms) of less than 10 N. Conclusion This study has commenced the process of quantifying tool-tissue interaction. The static measurements discussed here should evolve to include dynamic measurements such as shear, torque, and retraction forces, and be correlated with evidence of histological damage to tissue.

A nationwide assessment comparing nonelective open with minimally invasive complex colorectal procedures

AIM

The use of minimally invasive colorectal surgery has increased greatly for both benign and malignant disease. Studies evaluating complex procedures have been largely limited to elective indications. We aimed to compare the outcome of a laparoscopic with an open transverse (TC) and total abdominal colectomy (TAC) in the nonelective setting.

METHOD

Comparative analysis was made using the Nationwide Inpatient Sample (2008-11) of patients undergoing a nonelective TC or TAC identified by ICD-9-CM procedure codes. The risk-adjusted 30-day outcome was assessed using regression modelling accounting for patient characteristics, comorbidity and surgical procedure.

RESULTS

We identified 7261 admissions including 818 laparoscopic and 6443 open procedures. The mean age of the population was 65 ± 17 years and patients in the laparoscopic group were younger (56 ± 20 vs. 66 ± 17 years; P < 0.05). The rate of a single complication was lower in the laparoscopic group (26% vs. 38%; P < 0.01), but this did not remain significant following a logistic regression analysis. Mortality was significantly lower in the laparoscopic group (3.1% vs. 17%; P < 0.01) and this remained true after adjusting for covariates (OR = 0.62; P < 0.05). Laparoscopic cases were associated with a shorter median length of stay (10 vs. 13 days; P < 0.01) and hospital charge ($75,758 vs. $98,833; P < 0.01).

CONCLUSION

A nonelective laparoscopic TC or TAC is associated with an equivalent complication rate and lower mortality compared with an open operation. The results should encourage surgeons with the appropriate skills to consider a laparoscopic approach for nonelective pathology requiring a complex colectomy.

The current status of emergent laparoscopic colectomy: a population-based study of clinical and financial outcomes

BACKGROUND

Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA.

METHODS

A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group.

RESULTS

A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p < 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p < 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p < 0.001).

CONCLUSIONS

Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.

Urinary tract infection after surgery for colorectal malignancy: risk factors and complications

BACKGROUND

Over 4% of patients undergoing colorectal surgery develop postoperative urinary tract infection (UTI).

METHODS

Using 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program data for 47,781 patients, we examined independent risk factors and complications associated with UTI using multivariate logistic regression.

RESULTS

Independent predictors of UTI included female sex (odds ratio [OR] 1.705, 95% confidence interval [CI] 1.508 to 1.928), open procedure (OR 1.419, 95% CI 1.240 to 1.624), rectal procedure (OR 1.267, 95% CI 1.105 to 1.453), age greater than 65 years (OR 1.322, 95% CI 1.151 to 1.519), nonindependent functional status (OR 1.609, 95% CI 1.299 to 1.993), steroid use (OR 1.524, 95% CI 1.116 to 2.080), higher anesthesia class, and longer operative time. Patients with UTI had longer hospital stays (7 vs 12 days), higher reoperation rates (11.9% vs 5.1%), and higher 30-day mortality (3.3% vs 1.7%). Postoperative UTI correlated with other complications, including sepsis, surgical site infections, and pulmonary embolism (P < .001).

CONCLUSIONS

Postoperative UTI in colorectal surgery patients correlates with increased morbidity and mortality. Patients who contract postoperative UTI may be more likely to develop multiple complications.

Systematic review of emergent laparoscopic colorectal surgery for benign and malignant disease

Laparoscopic surgery has become well established in the management of both and malignant colorectal disease. The last decade has seen increasing numbers of surgeons trained to a high standard in minimally-invasive surgery. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. There is a perception that emergent surgery is technically more difficult and may lead to worse outcomes. The present review aims to provide a comprehensive and critical appraisal of the available literature on the use of laparoscopic colorectal surgery (LCS) in the emergency setting. The literature is broadly divided by the underlying pathology; that is, inflammatory bowel disease, diverticulitis and malignant obstruction. There were no randomized trials and the majority of the studies were case-matched series or comparative studies. The overall trend was that LCS is associated with shorter hospital stay, par or fewer complications but an increased operating time.Emergency LCS can be safely undertaken for both benign and malignant disease providing there is appropriate patient selection, the surgeon is adequately experienced and there are sufficient resources to allow for a potentially more complex operation.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

BACKGROUND

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis.

OBJECTIVE

The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes.

DESIGN

This is a population-based retrospective cohort study using administrative discharge data.

SETTING

This study was conducted in Ontario, Canada.

PATIENTS

All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012).

MAIN OUTCOME MEASURES

Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics.

RESULTS

There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001).

LIMITATIONS

There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data.

CONCLUSIONS

There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy

Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient's poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon's experience and the right selection of candidate patients cannot be understated.

Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study

BACKGROUND

Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies.

METHODS

The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan-Meier curves.

RESULTS

During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3-4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35-76) in the laparoscopic group versus 43 % (95 % CI 32-58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20-60) versus 37 % (95 % CI 27-50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy.

CONCLUSIONS

Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.

Systematic review of emergency laparoscopic colorectal resection

BACKGROUND

Laparoscopic surgery (LS) has become standard practice for a range of elective general surgical operations. Its role in emergency general surgery is gaining momentum. This study aimed to assess the outcomes of LS compared with open surgery (OS) for colorectal resections in the emergency setting.

METHODS

A systematic review was performed of studies reporting outcomes of laparoscopic colorectal resections in the acute or emergency setting in patients aged over 18 years, between January 1966 and January 2013.

RESULTS

Twenty-two studies were included, providing outcomes for 5557 patients: 932 laparoscopic and 4625 open emergency resections. Median (range) operating time was 184 (63-444) min for LS versus 148 (61-231) min for OS. Median (range) length of stay was 10 (3-23) and 15 (6-33) days in the LS and OS groups respectively. The overall median (range) complication rate was 27.8 (0-33.3) and 48.3 (9-72) per cent respectively. There were insufficient data to detect differences in reoperation and readmission rates.

CONCLUSION

Emergency laparoscopic colorectal resection, where technically feasible, has better short-term outcomes than open resection.

A stercoral perforation of the rectum

A stercoral perforation of the rectum due to a fecaloma is a rare disease with a high mortality rate. Although multiple case reports of colonic perforations have been published, the data regarding rectal perforations are limited. This case report will highlight one such case of a stercoral rectal perforation that was successfully treated with a laparoscopic operation.