Abstract Background Laparoscopic colorectal surgery remains one of the most challenging techniques to learn. Methods The authors collected studies that have compared hand-assisted laparoscopic ...surgery (HALS) and open surgery for the treatment of colorectal disease over the past 17 years. Data of interest for HALS and open surgery were subjected to meta-analysis. Results Twelve studies that included 1,362 patients were studied. In total, 2.66% of HALS procedures were converted to laparotomy. Compared with the open surgery group, blood loss, rate of wound infection, and ileus in the HALS group decreased, and incision length, recovery of gastrointestinal function, and hospitalization period were shorter. There were no significant differences in operating time, hospitalization costs, mortality, and complications, including urinary tract infection, pneumonia, and anastomotic leak, between the groups. Conclusions HALS has the advantages of minimal invasion, lower blood loss, shorter incision length, and faster recovery, and it can shorten the length of hospitalization without an increase in costs. The drawbacks are that a small number of patients who undergo HALS may need to be converted to laparotomy, and the oncologic safety and long-term prognosis are not clear.
Objective
To evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a ...preclinical setting.
Summary background data
Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots.
Methods
Cadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device’s safety in performing cholecystectomy or small bowel enterotomy.
Results
Nine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons’ preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (
n
= 6) and small bowel enterotomy (
n
= 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications.
Conclusions
This preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.
Background: The transversus abdominis plane (TAP) block is a peripheral nerve block that has been shown to significantly reduce postoperative opioid requirements. The use of dexamethasone in ...conjunction with peripheral nerve blocks has been proven to be an effective adjunct; however, its use remains offlabel. The objective of this study was to assess pain control in the first 48 postoperative hours after minimally invasive colorectal surgery in patients who received laparoscopically placed TAP blocks with and without the administration of perineural dexamethasone. Methods: Sixty patients undergoing laparoscopic colorectal surgery were included in this retrospective cohort study. Patients were allocated into 2 groups. Four patients were excluded owing to chronic opioid use and conversion to open surgery. Group 1 (TAP) received bilateral TAP blocks using 0.25% bupivacaine (1 mL/kg) with epinephrine. Group 2 (TAPD) received bilateral TAP blocks using 0.2 5% bupivacaine (1 mL/kg) with epinephrine in combination with dexamethasone (4-8 mg). Patient demographics; wound class; opioid use in the post-anesthetic care unit (PACU), at 24h and 48h; use of patientcontrolled analgesia (PCA); and length of stay were recorded. The study included 30 patients in the TAP block group and 26 patients in the TAP-D group. Results: There were no significant differences between the characteristics of both groups, including surgical indication and technique. There was a significant difference in PCA use between the 2 groups, with the TAP-D group having a 38% greater PCA use. Overall, TAP blocks with perineural dexamethasone did not significantly change opioid requirements in the PACU, at 24h or 48h postoperatively. Conclusion: A multivariate analysis adjusting for 10 confounders showed a trend toward lower opioid use in the first 48h with TAP-D (-9.4 mg); however, it was not significantly different (p = 0.242). A larger sample size with standardized PCA use can signify the benefit of adding perineural dexamethasone to conventional TAP blocks in the setting of minimally invasive colorectal surgery.
Objective
This study aimed to produce a comprehensive, up-to-date meta-analysis exploring the safety and efficacy of enhanced recovery programs after colorectal resection.
Method
Medline, Embase, and ...Cochrane database searches were performed for relevant studies published between January 1966 and April 2012. All randomized controlled trials on fast track (FT) colorectal surgery were reviewed systematically. The main end points were short-term morbidity, length of primary postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality.
Results
Seven randomized controlled trials with 852 patients were included. The total length of hospital stay mean difference (95 % confidence interval), −1.88 (−2.91, −0.86),
p
= 0.0003 and total complication rates relative risk (95 % confidence interval), 0.69 (0.51, 0.93),
p
= 0.01 were significantly reduced in the enhanced recovery group. There was no statistically significant difference in readmission (risk ratio (RR) 0.90; 95 % confidence interval (CI) 0.52 to 1.53,
p
= 0.69) and mortality rates (RR 1.02; 95 % CI 0.40 to 2.57,
p
= 0.97).
Conclusion
Results suggested that enhanced recovery after surgery pathways can be able to reduce the length of stay and complication rates after major colorectal surgery without compromising patient safety. Future studies have to define the active elements in order to improve future fast track protocols.
To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery.
EDA is mainstay of multimodal pain management within ...enhanced recovery pathways enhanced recovery after surgery (ERAS). For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious.
A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle.
Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range IQR, 3-7.5 days) in EDA patients and 4 days (IQR, 3-6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications 19 (33%) vs 35 (54%); P = 0.029 but a similar hospital stay 5 days (IQR, 4-8 days) vs 7 days (IQR, 4.5-12 days); P = 0.434. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted.
Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery.
Background
Opioids are a mainstay for postsurgical pain management, but have associated complications and costs, and contribute to the opioid epidemic. While efforts to reduce opioid use exist, ...little study has been done on opioid utilization and its impact across surgical approaches. Our goal was to evaluate the impact of opioid utilization on quality measures and costs after open and laparoscopic colorectal surgery.
Methods
The Premier database was reviewed for inpatient colorectal procedures from January 01, 2014, to September 30, 2015. Procedures were stratified into open and laparoscopic approaches, then “opioid” and “opioid-free” groups within each approach. Univariate analysis compared demographics, outcomes, and cost by opioid use and surgical approach. In the “opioid” groups, opioid consumption and duration were assessed across platforms. Multivariate regression analyzed the association between opioid use and surgical approach on costs and quality outcomes.
Results
50,098 procedures were evaluated—40.4% laparoscopic and 59.6% open. 6.6% of laparoscopic and 5.3% of open cases were “opioid free.” Across both approaches, patients over 65 were most likely opioid free, while the obese and cancer patients were most likely to use opioids. Length of stay was shorter, and post-discharge nursing needs and total costs were lower in the “opioid-free” group in both approaches (all
p
< 0.001). The median daily and total opioid consumption were lower with a laparoscopic approach (
p
< 0.001), which also had a shorter duration of use versus open cases (
p
< 0.001). Opioids were 20% more likely in open cases. Total costs were 16% greater with opioids and 24% greater in open surgery. Complications were 89% more likely in open surgery. Readmissions were increased by 14% with both opioid use and open surgery.
Conclusions
Opioid-free colorectal surgery results in improved outcomes, and laparoscopy further improves these results. Continued efforts to increase laparoscopy are key for reducing opioids and improving outcomes as we transition to value-based care.
There has been a resurgence of interest in the use of mechanical bowel preparation (MBP) and oral antibiotics (OAB) before elective colorectal surgery. Until now, clinical trials and meta-analyses ...have not compared all 4 approaches (MBP with OAB, OAB only, MBP only, or no preparation) simultaneously.
To perform a network meta-analysis to clarify which approach in colorectal surgery is associated with the lowest rate of surgical site infection (SSI).
Five electronic databases were searched, including PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club. and Database of Abstracts of Review of Effectiveness from database inception to November 27, 2017.
Only data from randomized clinical trials were included. Inclusion criteria were RCTs that reported on SSI rates or other complications based on MBP or OAB status. Quality of studies was appraised by the Cochrane Collaboration risk of bias tool.
The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Total, incisional, and organ/space SSI rates. Secondary outcomes included rates of anastomotic leak, mortality, readmissions/reoperations, urinary tract infection, and pulmonary complications.
Thirty-eight randomized clinical trials among 8458 patients (52.1% male) were included, providing 4 direct comparisons and 2 indirect comparisons for 8 outcome measures. On Bayesian analysis, MBP with OAB vs MBP only was associated with reduced SSI (odds ratio OR, 0.71; 95% equal-tail credible interval CrI, 0.57-0.88). There was no significant difference between MBP with OAB vs OAB only (OR, 0.95; 95% CrI, 0.56-1.62). Oral antibiotics without MBP was not associated with a statistically significant reduction in SSI compared with any other group (except for a risk reduction in organ/space SSI when indirectly compared with no preparation) (OR, 0.13; 95% CrI, 0.02-0.55). There was no difference in SSI between MBP only vs no preparation (OR, 0.84; 95% CrI, 0.69-1.02).
In this network meta-analysis of randomized clinical trials, MBP with OAB was associated with the lowest risk of SSI. Oral antibiotics only was ranked as second best, but the data available on this approach were limited. There was no difference between MBP only vs no preparation. In addition, there was no difference in rates of anastomotic leak, readmissions, or reoperations between any groups.
To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training.
Lapco ...provided competency-based supervised clinical training for specialist colorectal surgeons in England.
We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively.
One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% 95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively.
Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.
Aim The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery.
Method Randomized studies, published in English ...between January 1995 and July 2011, assessing analgesic and anaesthetic interventions in adults undergoing laparoscopic colorectal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. The efficacy and adverse effects of the analgesic techniques was assessed. The recommendations were based on procedure‐specific evidence from a systematic review and supplementary transferable evidence from other relevant procedures.
Results Of the 170 randomized studies identified, 12 studies were included. Overall, all approaches including ketorolac, methylprednisolone, intraperitoneal instillation of ropivacaine, intravenous lidocaine infusion, intrathecal morphine and epidural analgesia improved pain relief, reduced opioid requirements and improved bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L’Abbé plots of the data from the epidural analgesia studies included in this review indicate that the pain scores in the nonepidural groups, although higher than those in the epidural groups, were within an acceptable level (i.e. < 4/10).
Conclusion Infiltration of surgical incisions with local anaesthetic at the end of surgery, systemic steroids, conventional nonsteroidal anti‐inflammatory drugs or cyclooxygenase‐2‐selective inhibitors in combination with paracetamol with opioid used as rescue are recommended. Intravenous lidocaine infusion is recommended, but not as the first line of therapy. However, neuraxial blocks (i.e. epidural analgesia and spinal morphine) are not necessary based on high risk:benefit ratio.
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