Faculty Bibliography

Introduction & Objective: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction; however, rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger attainable graft dimension. Laparoscopic transanal minimally invasive surgery (TAMIS) has been described by our group. Due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the Intuitive da Vinci Xi system. We present a video which fully demonstrates our technique in the novel procedure of Robotic TAMIS (R-TAMIS) rectal mucosal harvest, for the purpose of onlay graft urethroplasty.
Method(s): A 53-year-old transgender male presented with postphalloplasty urethral stricture and underwent robotic rectal mucosal harvest. His past surgical history included vaginectomy and metoidioplasty usingBMGin 2008, followed by right forearmfree flap phalloplasty five months prior to presentation. The procedure was first demonstrated in an animal model using bovine colon. IRB approval was obtained. The surgery was performed under general anesthesia with the patient in lithotomy position. The GelPOINTTM Path Transanal Access Platform was used. As demonstrated, the rectal mucosa was dissected using robotic instruments after submucosal hydrodissection. Following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. The rectal mucosa graft was placed as an onlay for urethroplasty.
Result(s): Harvested graft size was 3.5 x 10cm, correlating well with surface area needed for urethral reconstruction as determined by the urologist. There were no intraoperative or postoperative complications, and the patient recovered well, without morbidity or mortality. He regained bowel function on the first postoperative day, and reported significantly less postoperative pain in comparison to his prior BMG harvest.
Conclusion(s): To our knowledge, this is the first use of R-TAMIS for harvest of rectal mucosal graft. The robotic approach is safe and feasible. This is a promising minimally-invasive technique to harvest rectal mucosa, which can be used for urethral or vaginal reconstruction. Demonstrated feasibility and potential avoidance of the challenging recovery associated withBMGharvest warrants further application and long-term evaluation of this procedure

BACKGROUND:Patients undergoing colon resection for Crohn's disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn's disease from a national database. METHODS:Patients who underwent colon resection for Crohn's disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted. RESULTS:A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04). CONCLUSION/CONCLUSIONS:Approximately one third of the patients who undergo colon resection for Crohn's disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.

Background: Postoperative ileus (POI) is a temporary delay of coordinated intestinal peristalsis following major abdominal surgery, leading to signifcant symptoms such as nausea, vomiting, abdominal pain, prolonged hospitalization, nosocomial complications, and physical deconditioning. Te use of opioids for postoperative pain control further exacerbates the problem. Opioids bind to the mu receptors in the intestinal tract, leading to gut hypomotility. Alvimopan, an oral, peripherally acting mu-opioid receptor antagonist, was FDA approved in 2008 for use before and afer bowel resection to help prevent and treat POI. Tere are no dedicated studies of alvimopan in patients with inflammatory bowel disease (IBD). Terefore, we conducted a study to investigate alvimopan's role in IBD patients who underwent either laparoscopic or open bowel resection. METHODS: A retrospective chart review was conducted at a 725-bed acute care teaching hospital in New York City between January 2012 and February 2017. Data collected included age, sex, type of IBD, length of stay, post-operative gastrointestinal symptoms (nausea, vomiting, constipation, abdominal distention, frst flatus, frst bowel movement, PO tolerance), and dose of alvimopan, were collected. Te primary outcome was time to GI recovery. Secondary outcomes were: time to frst flatus, time to frst bowel movement, time to tolerating a liquid diet, time to tolerating solid food, and total length of stay. Descriptive statistics reports were created through a secure web-based application called REDCap (Research Electronic Data Capture), and the data were exported into Stata to run further analyses. Of note, approximately 50% of patients who underwent bowel surgery afer March 2015 were placed on a "colon surgery pathwayTM, which is an order set dedicated to strategies that decrease length of stay and post-operative complications. Key features include early feeding, optimized analgesia regimen to allow patients to ambulate, encouraging use of incentive spirometry, and administration of alvimopan peri-procedurally. RESULTS: Of 247 patients, 121 received alvimopan (49.0%) and 126 (51.0%) did not. Te male to female ratio was 51:49. Te mean age of the control group was 44.4 + 16.3 and that of the alvimopan group was 43.2 + 16.4. Patients who received alvimopan had faster GI recovery, with a hazard ratio (HR) of 2.11 (P<0.001), shorter time to frst flatus (HR 2.02, P<0.001), shorter time to frst bowel movement (HR 1.93, P<0.001), shorter time to tolerating liquid diet (HR 2.48, P<0.001), and shorter time to tolerating solid food (HR 2.00, P<0.001). Afer controlling for type of bowel resected (large vs. small bowel), laparoscopic vs. open, age, and type of IBD (ulcerative colitis vs. Crohn's disease) using linear regression, patients who received alvimopan spent 2.59 fewer days in the hospital compared to the control group (P<0.01). CONCLUSION(S): Te results of this study suggest that alvimopan is effective in accelerating the time to GI recovery. Data analysis of all primary and secondary outcomes revealed that alvimopan had a statistically signifcant beneft during the post-operative period of IBD patients undergoing bowel resection. Length of stay for IBD patients was signifcantly decreased with peri-operative use of alvimopan

Introduction: Laparoscopic subtotal colectomy (LSTC) was initially controversial in patients with severe acute Ulcerative Colitis (UC) given patients' severity of illness, toxicity, and technical factors such as colonic dilatation. Since then, it has been shown to be feasible and safe in experienced hands. The development and adoption of the Intuitive da Vinci Xi Robot has allowed ease of use for multiquadrant surgery with minimal docking time. Our goal is to compare the intra-operative and postoperative outcomes of our early experience with Robotic Subtotal Colectomy (RSTC) vs. LSTC. Methods: We queried our prospectively maintained database of patients who underwent RSTC from 2015 to 2017. We identified patients who underwent RSTC for severe acute UC and compared them to a matched cohort of patients who underwent LSTC for the same diagnosis. Statistical significance was set at 0.05. The Intuitive da Vinci Xi was used for all Robotic approaches. Port placement and specimen extraction (via the ileostomy site) were uniform within both groups. Results: We identified 6 patients who underwent RSTC (4 females, median age: 41.5 years) and 13 patients who underwent LSTC (6 females, median age: 29 years). They were well matched for gender and demographic variables. The RSTC group had more patients with significant comorbidities (5/6= 83%) than the LSTC group (3/13=23%)(p=0.01). There wereno differences inoperative time (mean RSTC 314.0 vs. LSTC 294 minutes, p=0.5) orestimated blood loss (RSTC79mlvs. LSTC 75ml,p= 0.9). Mean length ofstay was shorter (1.2 days) for RTSC (3.4 vs.4.6 days, p=0.2) andreturnofbowel function was earlier (0.7 days) in the RSTC group (1.3 vs. 2 days, p=0.1), however, these were not statistically different. There were no intraoperative complications in either group. Postoperative major complication rates were similar (RSTC, 1/6=16% vs.3/13=23% for LSTC; p=0.9). Read-mission rate was less for the RSTC group (16%) than LSTC group (38.4%) (p=0.3). No patient required reoperation in the RSTC group (0%) vs. 2 patients (15.3%) in the LSTC (p=0.2). Conclusions: RSTC for severe acute UC is at least as safe as the laparoscopic approach. Although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to LSTC. RSTC was also associated with an earlier return of bowel function and shorter length of stay. A prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible