Faculty Bibliography

BACKGROUND: This study aimed to compare perioperative outcomes of patients undergoing robotic, laparoscopic, and open colectomy using a procedure-targeted database. METHODS: Retrospective review of patients undergoing elective colectomy in 2013 was conducted using the procedure-targeted database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Robotic, laparoscopic, and open groups were matched (1:1:1) based on age, gender, body mass index, surgical procedure, diagnosis and ASA classification. Demographics, comorbidities, and short-term (30 day) outcomes were compared. RESULTS: Out of 12 790 patients, 387 fulfilled criteria per group after matching. Univariate comparison showed operating time was longer (P < 0.001) and hospital stay was shorter (P < 0.001) in the robotic group. Morbidity (P < 0.001), superficial SSI (P < 0.001), bleeding requiring transfusion (P < 0.001), ventilator dependency (P = 0.003), and ileus (P < 0.001) rates were lower in the robotic group. After adjusting for confounders, outcomes were comparable between the groups except hospital stay which was shorter in the robotic group (P < 0.001). CONCLUSIONS: ACS-NSQIP data demonstrated several short-term advantages of robotic surgery compared with laparoscopic and open surgery.

BACKGROUND: There are no published studies on the impact of visceral adipose tissue (VAT) change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this historic cohort study was to evaluate the impact of excessive VAT gain on the outcomes of inflammatory bowel disease (IBD) patients with IPAA. METHODS: We evaluated all eligible patients with at least two sequential CT scans after pouch construction from our prospectively maintained Pouchitis Registry between 2002 and 2014. The visceral fat area (VFA) was measured on CT images. The study group comprised patients with a significant VAT gain (> 15%), and the control group was those without. The adverse outcomes of the pouch were defined as the new development of chronic pouch inflammation (chronic pouchitis, chronic cuffitis or Crohn's disease of the pouch), anastomotic sinus and the combination of above (the composite adverse outcome) or pouch failure, after the inception CT. RESULTS: Of 1564 patients in the Registry, 59 (3.8%) with at least 2 CT scans after pouch surgery were included. Twenty-nine patients (49.2%) were in the study group, and 30 (50.8%) were in the control group. The median duration from the inception to the latest CT was 552 (range: 31-2598) days for the entire cohort. We compared the frequency of new chronic pouch inflammation (13.8% vs 3.3%, P = 0.195), new pouch sinus (10.3% vs 0%, P = 0.112), composite adverse pouch outcome (24.1% vs 3.3%, P = 0.026) or pouch failure (10.3% vs 6.7%, P = 0.671) between the two groups. Kaplan-Meier plot for time-to-pouch failure between the pouch patients with or without excessive body mass index (BMI) gain (> 10%) showed statistical difference (P = 0.011). Limited stepwise multivariate analysis showed that excessive VAT gain (odds ratio = 12.608, 95% confidence interval: 1.190-133.538, P = 0.035) was an independent risk factor for the adverse pouch comes. CONCLUSIONS: In this cohort of ileal pouch patients, excessive VAT gain as well as gain in BMI after pouch construction was found to be associated with poor long-term outcomes.

BACKGROUND: Previous work from our institution has characterized the learning curve for open ileal pouch-anal anastomosis (IPAA). The purpose of the present study was to assess the learning curve of minimally invasive IPAA. METHODS: Perioperative outcomes of 372 minimally invasive IPAA by 20 surgeons (10 high-volume vs. 10 low-volume surgeons) during 2002-2013, included in a prospectively maintained database, were assessed. Predicted outcome models were constructed using perioperative variables selected by stepwise logistic regression, using Akaike's information criterion. Cumulative sums (CUSUM) of differences between observed and predicted outcomes were graphed over time to identify possible improvement patterns. RESULTS: Institutional pelvic sepsis and other pouch morbidity rates (hemorrhage, anastomotic separation, pouch failure, fistula) significantly decreased (18.2 vs. 7.0 %, CUSUM peak after 143 cases, p = 0.001; 18.4 vs. 5.3 %, CUSUM peak after 239 cases, respectively, p < 0.001). Institutional total proctocolectomy mean operative times significantly decreased (307 min vs. 253 min, CUSUM peak after 84 cases, p < 0.001), unlike completion proctectomy (p = 0.093) or conversion rates (10 vs. 5.4 %, p = 0.235). Similar learning curves were identified among high-volume surgeons but not among low-volume surgeons. Learning curves were identified in the two busiest individual surgeons for pelvic sepsis (peaks at 47 and 9 cases, p = 0.045 and p = 0.002) and in one surgeon for operative times (CUSUM peak after 16 and 13 cases for both total proctocolectomy and completion proctectomy (p < 0.001 and p = 0.006) but not for other pouch complications (peak at 49 and 41 cases, p = 0.199 and p = 0.094). CONCLUSION: Pouch complications, particularly pelvic sepsis, are the most consistent and relevant learning curve end points in laparoscopic IPAA.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

PURPOSE/OBJECTIVE:The aim of this study is to compare short-term outcomes of laparoscopic versus open Hartmann reversal. MATERIALS AND METHODS/METHODS:Patients who underwent Hartmann reversal between January 2005 and September 2014 were identified and matched for age, sex, body mass index, American Society of Anesthesiologists score, and creation of diverting ileostomy to open counterparts. Patient characteristics and postoperative outcomes (30 d) were evaluated. RESULTS:Eighteen patients with laparoscopic Hartmann reversal were matched to 18 open patients. There were no differences between laparoscopic versus open groups in terms of operative time (157.7±52.2 vs. 151.5±49.3 min, P>0.05) or overall complication rates [6 (33.3%) vs. 6 (33.3%) (P>0.05)]. No anastomotic leaks or mortality occurred in either group. However, the laparoscopic group was associated with significantly decreased estimated blood loss (114±103 vs. 217±125 mL, P<0.05), faster return of bowel function (3.2±0.6 vs. 4±0.6 d, P<0.05), and reduced hospital stay (5.4±3.1 vs. 8.3±4.8 d, P<0.05). CONCLUSIONS:Laparoscopic Hartmann reversal can be safely performed with better short-term outcomes in carefully selected patients.

OBJECTIVE: The aim of this study is to identify the association between early postoperative troponin elevations and outcomes after major colorectal surgery. BACKGROUND: Myocardial infarction is the leading cause of death after noncardiac surgery. Most postoperative myocardial infarctions are clinically silent, and asymptomatic troponin elevations have the same early mortality as symptomatic infarctions. METHODS: Patients over the age of 45, undergoing major colorectal surgery from March 2015 to January 2016, were identified. Plasma troponin T concentrations were prospectively collected within 24 and 48 hours after surgery. Characteristics, evaluations, management, and outcomes of patients with elevated troponin concentrations were analyzed. Mortality within the follow-up period was the primary end point. RESULTS: A total of 1020 patients were screened with postoperative troponin concentrations. Fifty patients had troponin concentrations >0.01 ng/mL. Patients rarely (16%) had ischemic symptoms. Cardiology was consulted for 23 patients and started on medical therapy. Seventeen of these patients were alive at follow-up. Ten patients (20%) with troponin concentrations >0.01 ng/mL died within the follow-up period, 7 of which had concentrations >/=0.03 ng/mL. CONCLUSIONS: Most postoperative myocardial injury is asymptomatic and may only be detected by routine troponin screening. Elevated troponin concentrations after colorectal surgery may facilitate identifying patients at postoperative risk and prompt appropriate testing. Early intervention in select patients may lead to potential reduction of mortality after major colorectal surgery.

BACKGROUND: Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. OBJECTIVE: The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN: Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS: The study was conducted at a tertiary care research center. PATIENTS: Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES: Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. RESULTS: Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

PURPOSE: Risks and benefits of colorectal cancer resection in octogenarians are not clearly defined. This study aimed to assess the relationship between morbidity and mortality within 1 year after colorectal cancer resection in octogenarians compared with other age groups. METHODS: A single-institution, prospectively maintained database was queried to identify patients with sporadic, pathological stages I-III colorectal adenocarcinoma, electively undergoing radical resection with curative intent between 2000 and 2012. Patients were divided into three age groups: 'octogenarians' if >/=80 years of age; 'intermediate' if >/=65 and <80 years of age; and 'younger' if <65 years of age. RESULTS: Overall, 2485 patients fulfilled the inclusion criteria-326 in the octogenarian age group, 949 in the intermediate age group, and 1210 in the younger age group. Postoperative morbidity disproportionally increased 1-year mortality in octogenarians when compared with the younger age group (37 vs. 6.5 %; p < 0.001). Anastomotic leak, abdominopelvic abscess, reoperation, and readmission rates were comparable among different age groups, but were associated with a disproportionate risk of 1-year mortality in octogenarians (67, 43, 33, and 41 %, respectively). Multivariate analysis indicated that older age and postoperative complications were the only two independent variables associated with 30- and 90-day mortality. Besides these, American Society of Anesthesiologists (ASA) and pathological stage III were additional independent variables associated with 1-year mortality. An interaction test confirmed that age and postoperative complications were independent variables, with additive effect on 30-day, 90-day, and 1-year mortality. CONCLUSIONS: Age plays an important and independent role in affecting mortality when complications occur following surgery for colorectal cancer. The full magnitude of postoperative risks should be taken into consideration when discussing colorectal cancer surgery in octogenarians.