Faculty Bibliography

PURPOSE/OBJECTIVE:Distal rectal stapling is often challenging because of limited space and visibility. We compared two stapling devices in the distal rectum in a cadaver study: the iDrive™ right angle linear cutter (RALC) (Covidien, New Haven, CT) and the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH). METHODS:Twelve male cadavers underwent pelvic dissection by 4 surgeons. After rectal mobilization as in a total mesorectal excision, the staplers were applied to the rectum as deep as possible in both the coronal and sagittal positions. The distance from the pelvic floor was measured for each application. A questionnaire rated the visibility and access of the stapling devices. Measurements were taken between pelvic landmarks to see what anatomic factors hinder the placement of a distal rectal stapler. RESULTS:The median (range) distance of the stapler from the pelvic floor in the coronal position for the RALC was 1.0 cm (0-4.0) vs. 2.0 cm (0-5.0) for the CC, p = 0.003. In the sagittal position, the median distance was 1.6 cm (0-3.5) for the RALC and 3.3 cm (0-5.0) for the CC, p < 0.0001. The RALC scored better than the CC in respect to: 1. interference by the symphysis pubis, 2. number of stapler readjustments, 3. ease of placement in the pelvis, 4. impediment of visibility, 5. ability to hold and retain tissue, 6. visibility rating, and 7. access in the pelvis. A shorter distance between the tip of the coccyx and the pubic symphysis correlated with a longer distance of the stapler from the pelvic floor (p = 0.002). CONCLUSIONS:The RALC is superior to the CC in terms of access, visibility, and ease of placement in the deep pelvis. This could provide important clinical benefit to both patient and surgeon during difficult rectal surgery.

BACKGROUND:Surgical site infections (SSIs) cause morbidity after elective colorectal surgery, and antibiotic prophylaxis can decrease SSIs. The aim of this study was to determine compliance with an antibiotic administration protocol, including regimen, initial dose timing, and re-dosing, and determine the risk of SSI associated with each. We hypothesized that appropriate antibiotic administration reduces the risk of SSI. METHODS:Retrospective review from a prospective database of a random sample of patients undergoing elective abdominal colorectal procedures with anastomosis. Antibiotic regimens, initial dose timing (IDT), and re-dosing were evaluated. Appropriate regimens covered gram-positive cocci, gram-negative bacilli, and anaerobes. The IDT was considered proper if completed within 30 min prior to incision; re-dosing parameters were determined pharmacokinetically for each agent. The main outcome was SSI. Sequential logistic models were generated: Model 1 assessed antibiotic administration factors, whereas Model 2 controlled for patient and clinical factors, including disease process, patient characteristics, intra-operative factors, and post-operative factors. RESULTS:Six hundred five patients (mean age 59.7 [standard deviation 17.8] years, 42.8% male) were included. The most common diagnoses were cancer (38.8%) and inflammatory bowel disease (22.0%). Seventy-six patients (12.6%) had superficial or deep incisional SSI, and 54 (8.9%) had organ/space SSI. Regimens included cefazolin + metronidazole for 219 patients (36.2%), cefoxitin for 214 (35.4%), and levofloxacin + metronidazole for 48 (7.9%). One hundred fourteen patients (18.8%) received other/nonstandard regimens, and ten had no documented antibiotic prophylaxis. Fifty-five patients (9.1%) received insufficient coverage, whereas 361 patients (59.7%) had proper IDT, and 401 regimens (66.3%) were re-dosed properly. In Model 1, the use of other/nonstandard regimens (odds ratio [OR] 2.069; 95% confidence interval [CI] 1.078-1.868) and early administration of the initial prophylaxis dose (OR 1.725; 95% CI 1.147-2.596) were associated with greater odds of SSI. After adding clinical factors in Model 2, both of these factors remained significant (OR 2.505; 95% CI 1.066-5.886 and OR 1.733; 95% CI 1.017-2.954, respectively). CONCLUSIONS:Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of SSI after elective colorectal surgery with intestinal anastomosis.

OBJECTIVE:Surgical site infections are a major source of morbidity after colorectal surgery. The aim of this study was to explore differences between incisional and organ/space surgical site infection types by evaluating risk factors, National Nosocomial Risk Index Scores, and clinical outcomes. DESIGN/METHODS:A random sample of adults undergoing abdominal colorectal surgery between June 2001 and July 2008 was extracted from a colorectal surgery practice database. Patient factors, comorbidities, intraoperative factors, postoperative factors, and infection were collected; risk score (from -1 to 3 points) was calculated. Variables associated with surgical site infection by univariate analysis were incorporated in a multivariable model to identify risk factors by infection type. Infection risk by risk score was evaluated by logistic regression. Length of stay, readmission, and mortality were examined by infection type. RESULTS:Six hundred fifty subjects were identified: 312 were male, age was 59.8 (SD 17.8) years. Common preoperative diagnoses included colorectal cancer (36.9%) and inflammatory bowel disease (21.7%). Forty-five cases were emergencies, and 171 included rectal resections. Eighty-two patients developed incisional and 64 developed organ/space surgical site infections. Body mass index was associated with incisional infection (OR 1.05, 95% CI 1.00-1.09), whereas previous radiation (OR 4.49, 95% CI 1.53-13.18), postoperative hyperglycemia (OR 2.99, 95% CI 1.41-6.34), preoperative [albumin] (OR 0.52, 95% CI 0.36-0.76), and case length (OR 1.26, 95% CI 1.08-1.47) were associated with organ/space infection. A risk score of 2 and above, compared with a score of <2, predicted organ/space (OR 5.92, 95% CI 3.16-11.09) but not incisional infection (OR 0.95, 95% CI 0.41-2.16). Organ/space infections were associated with longer length of stay (P = .006) and higher readmission rates (P < .001) than incisional infections. CONCLUSIONS:Risk factors for surgical site infections differ by type of infection. Clinical outcomes and value of the risk index score are different by infection type. It may be prudent to consider incisional and organ/space surgical site infections as different entities for patients undergoing colorectal surgery.

BACKGROUND:For complex right colon polyps, not removable using colonoscopy, right colon resection is considered the optimal treatment. Combined endoscopic-laparoscopic surgery, using both laparoscopy and CO2 colonoscopy, has been introduced as a new approach for these complex colon polyps with intent to avoid bowel resection. OBJECTIVE:This study aimed to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery used for treatment of complex right colon polyps. DESIGN/METHODS:This is a retrospective study of patients undergoing combined endoscopic-laparoscopic surgery for treatment of benign right colon polyps from 2003 to 2008. SETTINGS/METHODS:This is a single-institution study. PATIENTS/METHODS:Twenty-three patients with complex right colon polyps were included. MAIN OUTCOME MEASURES/METHODS:The main outcome measures included the length of hospital stay, postoperative complications, and polyp recurrence. RESULTS:Of 23 patients, 20 (87%) patients had their polyp removed successfully by combined endoscopic-laparoscopic surgery and 3 (13%) needed laparoscopic resection, after laparoendoscopic evaluation. The median length of hospital stay was 2 days (range, 1-5), and there were no postoperative complications. Median follow-up time was 12 months. Three patients had recurrent polyps, and the recurrence-free interval at 36 months was 55.7% (95% CI = 8.6%, 87.0%). All recurrences were benign polyps and were removed by colonoscopic snaring. CONCLUSIONS:Combined endoscopic-laparoscopic surgery can be safely offered to selected patients with benign right colon polyps that can not be removed by colonoscopy. This combined approach may provide a viable alternative to right colon resection for complex benign colon lesions and warrants future investigation.

BACKGROUND:Although evidence suggests that laparoscopic colectomy (LC) results in faster gastrointestinal (GI) recovery than open bowel resection, previous studies were performed at single institutions or generally not controlled for diet introduction or perioperative care, making the results difficult to interpret. A prospective, observational, multicenter study was planned to investigate GI recovery, length of hospital stay (LOS), and postoperative ileus (POI)-related morbidity after LC. METHODS:Patients scheduled to undergo LC or hand-assisted laparoscopic (HAL) bowel resection and to receive opioid-based postoperative intravenous patient-controlled analgesia were enrolled in 16 U.S. centers. The study design was similar to that for trials of alvimopan phase 3 open laparotomy bowel resection using a standardized accelerated postoperative care pathway. The primary end points were time to upper and lower GI recovery (GI-2: toleration of solid food and bowel movement) and postoperative LOS. The secondary end points included POI-related morbidity (postoperative nasogastric tube insertion or investigator-assessed POI resulting in prolonged hospital stay or readmission), conversion rate, and protocol-defined prolonged POI (GI-2 > 5 postoperative days). RESULTS:In this study, 148 patients received hemicolectomy by the LC (42 left and 67 right) or HAL (39 left) approach. The conversion rate was 18.8% (25.4% LC left, 17.3% HAL left, 15% LC right). The mean time to GI-2 recovery was 4.4 days, and the mean postoperative LOS was 4.9 days, neither of which varied substantially by surgical approach. Prolonged POI occurred for 15 patients (10.1%), and POI-related morbidity occurred for 17 patients (11.5%). No patients were readmitted because of POI, whereas 3 patients (2%) were readmitted for all other causes. CONCLUSIONS:Mean GI recovery and LOS after LC were accelerated compared with those for patients in open laparotomy bowel resection clinical trials or those reported in large hospital databases (0.7 and 1.7-2.2 days, respectively). Overall POI-related morbidity was similar between the open bowel resection and LC populations, demonstrating that POI continues to present with important morbidity regardless of the surgical approach.

PURPOSE/OBJECTIVE:The use of laparoscopy surgery in the management of rectal cancer is controversial, especially in the mid and low rectum. The aim of this study was to determine oncologic and long-term outcomes after laparoscopic and hand-assisted laparoscopic surgery for mid and low rectal cancer. METHODS:Between January 1999 and December 2006, 185 patients had surgery for rectal cancer; 103 these patients had mid and low rectal cancer. The source of data was inpatient/outpatient medical records. Telephone interviews were conducted for all patients. Actuarial survival was calculated with use of the Kaplan-Meier method. RESULTS:Hand-assisted laparoscopic surgery was performed in 58 (56.3%) patients, and pure laparoscopic surgery in 45 (43.7%) patients. Mean follow-up time was 42.1 months. The conversion rate was 2.9%. All specimen margins were negative. The anastomotic leak rate was 7.8% (n = 8). There was no 30-day mortality. Local recurrence rate was 5% at five years. Overall survival was 91% and disease-free survival was 73.1% at five years. CONCLUSION/CONCLUSIONS:Laparoscopic surgical techniques for mid and low rectal cancer seem safe and feasible with acceptable oncologic and long-term outcomes. Further studies, comparing laparoscopic and open methods, are warranted.

BACKGROUND:Hand-assisted laparoscopic surgery (HALS) requires a larger incision compared with standard laparoscopic surgery (SLS). Whether this leads to more longterm complications, such as incisional hernia (IH) and small bowel obstruction (SBO), has not been studied to date. This study compares the rates of SBO and IH after HALS and SLS in patients undergoing operations for colon and rectal diseases. STUDY DESIGN/METHODS:From a colorectal database, 536 consecutive patients were identified who underwent bowel resection using HALS (n = 266) and SLS (n = 270) between 2001 to 2006. All medical records were reviewed, and all subjects were contacted by telephone for accurate followup. Statistical analysis was performed using chi-square, Fisher's exact, and Mann-Whitney U tests, where appropriate. RESULTS:Median followup was 27 months (range 1 to 72 months). Overall conversion rate was 2.2% (SLS, n = 4; HALS, n = 8). Median incision size in HALS (75 mm; range 60 to 140 mm) was larger than SLS (45 mm; range 30 to 130 mm; p < 0.01). Despite the larger wound, the incidence of IH was similar between both approaches (HALS, n = 16 [6.0%] versus SLS, n = 13 [4.8%]; p < 0.54). Rate of SBO was also comparable (HALS, n = 11 [4.1%] versus SLS, n = 20 [7.4%]; p = 0.11). Wound infections occurred similarly between both groups (HALS, n = 18 [6.8%]; SLS, n = 13 [4.8%]; p = 0.33). Converted patients had a higher rate of IH compared with nonconverted ones (25% versus 5%; p = 0.02), although the rate of SBO was similar (8.3% versus 5.7%; p = 0.51). CONCLUSIONS:HALS does not lead to more longterm complications of IH and SBO when compared with SLS for resections of the colon and rectum.

PURPOSE/OBJECTIVE:The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy. METHODS:A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm. RESULTS:Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted (P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history (P < 0.0001). CONCLUSIONS:Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy.