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A Randomized Noninferiority Trial of Electroacupuncture Versus Fast-Track Perioperative Program for Reducing Duration of Postoperative Ileus and Hospital Stay after Laparoscopic Colorectal Surgery
extensive use of intraoperative ultrasonography. The aim of the study is to analyze surgical strategy applied in this complex CRLM presentations and devise a flow chart according to patients characteristics. Methods: 457 consecutive patients undergoing first liver resection (LR) for CLM between 2002 and 2015 were considered. Patients carrier of multiple (≥4) CLM with intrahepatic major vascular contact were included. Results: 164 patients were analyzed. OSH was possible in 155 (95%) patients including 12 SERPS, 1 transversal hepatectomy, 2 mini-mesohepatectomies, 6 liver tunnels. 9 Patients underwent two stage hepatectomy (TSH). One hundred and three patients (63%) had a monolateral main intravascular contacts whereas 61 patients (37%) had bilateral vascular contacts. The median number of resected CRLMs were 7 ( range 4-48) and 63 (38%) patients had >10 nodules. Seventy patients (42%) had a main intrahepatic vascular detachment or reconstruction.10 patients of the OSH group underwent major hepatectomy associated to limited resections. Reasons to perform major hepatectomies for OSH group were the following: - infiltration of umbilical portion (5/10) for left hepatectomy. - uncountable, disappearing, huge lesions (4/10, 40%) or 360° infiltration of the right portal branch (1/10, 10%) for right hepatectomy. Twenty four patients have concomitant extrahepatic disease. Twelve patients have lung deposits (12/ 24, 50%). Mortality and morbidity rates were 1,2% and 36%. Five-year overall survival (OS) was 32% (median overall survival 40,2 months). Disease free survival at 5 years was 17% (median 12 months). TSH patients compared to OSH showed no difference except for more cycles of chemotherapy (>6 cycles), higher rate of patients with more than 10 lesions, associated surgical resection (colon resections), more vascular infiltration and more parenchymal R1. According to these findings we devised a flow chart for multiple bilobar CRLM treatment. At univariate analysis re-resection was the only positive prognostic factors for OS (p< 0,001). Conclusions: OSH for CRLMs is safe and effective. According to the evidence that re-resection is a protective factor for OS, parenchymal spare resections must be attempted whenever possible to increase FRL.TSH must be reserved for a selected number of patients.
removal. 50 patients (30%) had ureteric stent placement preoperatively. All patients underwent sigmoid colectomy but only 54 patients (33%) had concurrent bladder repair. 118 patients (73%) had postoperative cystograms to evaluate leak before their FC was removed (62 [78%] patients in the early group and 56 [68%] patients in the late group). 4 patients (5%) experienced urinary tract infection in the early removal group whereas 9 patients (11%) had urinary complications in the late group (p=0.16). Morbidity was higher among patients who had late FC withdrawal (p=0.008). Length of stay was significantly longer in patients with late FC removal (10.3 ±8.2 vs. 5.8 ±2.1 days, p<0.0001). Conclusion: Late FC removal in patients operated for colovesical fistula secondary to diverticulitis increased postoperative 30-day complications when compared to early FC removal. It may be preferable to perform a cystogram early and if no leak is demonstrated to remove the indwelling catheter to decrease perioperative morbidity and potential length of hospital stay. Comparison of demographics, preoperative comorbidities and surgical details between the groups.
Fig 1. An example of parenchimal spare resection: liver tunnel associated with multiple liver resection in a 71 year old patient with multiple bilobar CRLM. a) intraoperative picture liver tunnel with the exposure on the cut surface of the RHV and MHV. b-c) preoperative CT scan. Abbreviations. RHV: right hepatic vein IVC: inferior vena cava, MHV: middle hepatic vein, LHV: left hepatic vein, V7: vein draining segment 7 tributary of the RHV, P4s: portal pedicle of segment 4, P2: portal pedicle segment 2, P3: portal pedicle segment 3
Values reported as mean (percentage) otherwise noted. * Values reported as mean (min-max).
A RANDOMIZED NONINFERIORITY TRIAL OF ELECTROACUPUNCTURE VERSUS FAST-TRACK PERIOPERATIVE PROGRAM FOR REDUCING DURATION OF POSTOPERATIVE ILEUS AND HOSPITAL STAY AFTER LAPAROSCOPIC COLORECTAL SURGERY Simon S. Ng, Wing Wa Leung, Simon K. Chan, Tony Mak, Sophie S. Hon, Dennis Ngo, Simon Chu, Oky C. Lam, Yee Ni C. Wong, Janet F. Lee Background and Objective: Ample evidence suggested that ‘fast-track' (FT) perioperative program can reduce surgical stress and accelerate postoperative recovery after colorectal surgery. Our recent study also demonstrated that electroacupuncture (EA) at Zusanli, Sanyinjiao, Hegu, and Zhigou can enhance recovery after laparoscopic colorectal surgery (Ng et al. Gastroenterology 2013; 144: 307-313). This prospective, randomized, noninferiority trial aimed to compare the efficacy of EA and FT program in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery. Methods: Between January 2014 and March 2016, 164 patients undergoing elective laparoscopic resection of colonic and upper rectal cancer without conversion were randomized to receive either EA or FT program (82 per group). The primary outcome was time to defecation. Secondary outcomes were hospital stay, 30-day morbidity and readmission rates, and overall cost. Data were analyzed by intention-to-treat principle. Results: The demographic data of the two groups were comparable. The overall protocol compliance rate in the FT group was 85%. The mean time to defecation in the EA and FT groups was 79.0 ± 42.2 hours and 72.9 ± 30.0 hours (difference = 6.1 hours; 95% confidence interval [CI], -5.2 hours to 17.5 hours), respectively (P = 0.286). Noninferiority was demonstrated as the upper limit of 95% CI for the difference was within the prespecified noninferiority margin of 24 hours. There was a trend towards shorter mean total postoperative hospital stay in the EA group (5.8 ± 2.9 days vs. 6.8 ± 5.3 days, P = 0.119). The overall 30-day morbidity rate in the EA and FT groups was similar (13.4% vs. 22.0%, P = 0.152). There was no difference in readmission rates between the two groups. The implementation cost of EA was significantly lower than the cost of implementation of the FT program (US$128 ± 46 vs. US$509 ± 13, P <0.001). The total direct cost was also lower in the EA group than in the FT group (US$15,192 ± 3,164 vs. US$17,005 ± 7,661, P = 0.049). Conclusions: EA is noninferior to FT program in reducing the duration of postoperative ileus after laparoscopic colorectal surgery. Postoperative hospital stay and overall morbidity rate are also similar between the two perioperative management strategies. EA may be the preferred perioperative therapy for laparoscopic colorectal surgery because it is simpler to implement, less labor intensive, and less expensive than the FT program. (ClinicalTrials.gov number, NCT02059603) This study was supported by the Health and Medical Research Fund, Food and Health Bureau, The Government of the Hong Kong SAR (Reference Number 11120121); PI: Professor Simon SM Ng.
Fig 2. Flow chart of surgical treatment of multiple bilobar CRLM with main intrahepatic vascular contact. CRLM: colorectal liver metastases CHT: chemotherapy, P5-8: right anterior portal branch, P6-7: right posterior portal branch, FRL: future remnant liver, LR: limited resection.
Mo1621 EARLY REMOVAL OF FOLEY CATHETER AFTER SURGERY FOR COLOVESICAL FISTULA SECONDARY TO DIVERTICULITIS: FRIEND OR FOE? H. Hande Aydinli, Gokhan Ozuner Introduction: Diverticulitis is the most common disease causing colovesical fistula. Resection and primary anastomosis with or without bladder intervention is the preferred surgical approach. The optimal postoperative management in terms of foley catheter (FC) withdrawal is debated in the literature. The aim of this study was to share our institutional experience while evaluating the difference in the outcomes between early versus late FC removal. Methods: All patients who underwent colorectal surgery for diverticulitis complicated with colovesical fistula between 01/1994-11/2015 were identified from an IRB-approved, prospectively maintained institutional database. Patients were divided into two groups according to their FC removal day after index surgery (≥7 days, <7days). Morbidity was defined as occurrence of at least one of the following within 30 days of surgery; pneumonia, ileus, small bowel obstruction, urinary tract infection, surgical site infection, wound dehiscence, sepsis, anastomotic leak, arrhythmia and venous thromboembolism. Results: A total of 162 patients were identified with a mean age of 63 (34-88). 58 patients (36%) were female. Patient demographics, preoperative comorbidities, and operative details are summarized in the table. Mean FC withdrawal day was 8.8 days (1-65). 80 patients (49%) had early FC
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removal. 50 patients (30%) had ureteric stent placement preoperatively. All patients underwent sigmoid colectomy but only 54 patients (33%) had concurrent bladder repair. 118 patients (73%) had postoperative cystograms to evaluate leak before their FC was removed (62 [78%] patients in the early group and 56 [68%] patients in the late group). 4 patients (5%) experienced urinary tract infection in the early removal group whereas 9 patients (11%) had urinary complications in the late group (p=0.16). Morbidity was higher among patients who had late FC withdrawal (p=0.008). Length of stay was significantly longer in patients with late FC removal (10.3 ±8.2 vs. 5.8 ±2.1 days, p<0.0001). Conclusion: Late FC removal in patients operated for colovesical fistula secondary to diverticulitis increased postoperative 30-day complications when compared to early FC removal. It may be preferable to perform a cystogram early and if no leak is demonstrated to remove the indwelling catheter to decrease perioperative morbidity and potential length of hospital stay. Comparison of demographics, preoperative comorbidities and surgical details between the groups.
Fig 1. An example of parenchimal spare resection: liver tunnel associated with multiple liver resection in a 71 year old patient with multiple bilobar CRLM. a) intraoperative picture liver tunnel with the exposure on the cut surface of the RHV and MHV. b-c) preoperative CT scan. Abbreviations. RHV: right hepatic vein IVC: inferior vena cava, MHV: middle hepatic vein, LHV: left hepatic vein, V7: vein draining segment 7 tributary of the RHV, P4s: portal pedicle of segment 4, P2: portal pedicle segment 2, P3: portal pedicle segment 3
Values reported as mean (percentage) otherwise noted. * Values reported as mean (min-max).
A RANDOMIZED NONINFERIORITY TRIAL OF ELECTROACUPUNCTURE VERSUS FAST-TRACK PERIOPERATIVE PROGRAM FOR REDUCING DURATION OF POSTOPERATIVE ILEUS AND HOSPITAL STAY AFTER LAPAROSCOPIC COLORECTAL SURGERY Simon S. Ng, Wing Wa Leung, Simon K. Chan, Tony Mak, Sophie S. Hon, Dennis Ngo, Simon Chu, Oky C. Lam, Yee Ni C. Wong, Janet F. Lee Background and Objective: Ample evidence suggested that ‘fast-track' (FT) perioperative program can reduce surgical stress and accelerate postoperative recovery after colorectal surgery. Our recent study also demonstrated that electroacupuncture (EA) at Zusanli, Sanyinjiao, Hegu, and Zhigou can enhance recovery after laparoscopic colorectal surgery (Ng et al. Gastroenterology 2013; 144: 307-313). This prospective, randomized, noninferiority trial aimed to compare the efficacy of EA and FT program in reducing the duration of postoperative ileus and hospital stay after laparoscopic colorectal surgery. Methods: Between January 2014 and March 2016, 164 patients undergoing elective laparoscopic resection of colonic and upper rectal cancer without conversion were randomized to receive either EA or FT program (82 per group). The primary outcome was time to defecation. Secondary outcomes were hospital stay, 30-day morbidity and readmission rates, and overall cost. Data were analyzed by intention-to-treat principle. Results: The demographic data of the two groups were comparable. The overall protocol compliance rate in the FT group was 85%. The mean time to defecation in the EA and FT groups was 79.0 ± 42.2 hours and 72.9 ± 30.0 hours (difference = 6.1 hours; 95% confidence interval [CI], -5.2 hours to 17.5 hours), respectively (P = 0.286). Noninferiority was demonstrated as the upper limit of 95% CI for the difference was within the prespecified noninferiority margin of 24 hours. There was a trend towards shorter mean total postoperative hospital stay in the EA group (5.8 ± 2.9 days vs. 6.8 ± 5.3 days, P = 0.119). The overall 30-day morbidity rate in the EA and FT groups was similar (13.4% vs. 22.0%, P = 0.152). There was no difference in readmission rates between the two groups. The implementation cost of EA was significantly lower than the cost of implementation of the FT program (US$128 ± 46 vs. US$509 ± 13, P <0.001). The total direct cost was also lower in the EA group than in the FT group (US$15,192 ± 3,164 vs. US$17,005 ± 7,661, P = 0.049). Conclusions: EA is noninferior to FT program in reducing the duration of postoperative ileus after laparoscopic colorectal surgery. Postoperative hospital stay and overall morbidity rate are also similar between the two perioperative management strategies. EA may be the preferred perioperative therapy for laparoscopic colorectal surgery because it is simpler to implement, less labor intensive, and less expensive than the FT program. (ClinicalTrials.gov number, NCT02059603) This study was supported by the Health and Medical Research Fund, Food and Health Bureau, The Government of the Hong Kong SAR (Reference Number 11120121); PI: Professor Simon SM Ng.
Fig 2. Flow chart of surgical treatment of multiple bilobar CRLM with main intrahepatic vascular contact. CRLM: colorectal liver metastases CHT: chemotherapy, P5-8: right anterior portal branch, P6-7: right posterior portal branch, FRL: future remnant liver, LR: limited resection.
Mo1621 EARLY REMOVAL OF FOLEY CATHETER AFTER SURGERY FOR COLOVESICAL FISTULA SECONDARY TO DIVERTICULITIS: FRIEND OR FOE? H. Hande Aydinli, Gokhan Ozuner Introduction: Diverticulitis is the most common disease causing colovesical fistula. Resection and primary anastomosis with or without bladder intervention is the preferred surgical approach. The optimal postoperative management in terms of foley catheter (FC) withdrawal is debated in the literature. The aim of this study was to share our institutional experience while evaluating the difference in the outcomes between early versus late FC removal. Methods: All patients who underwent colorectal surgery for diverticulitis complicated with colovesical fistula between 01/1994-11/2015 were identified from an IRB-approved, prospectively maintained institutional database. Patients were divided into two groups according to their FC removal day after index surgery (≥7 days, <7days). Morbidity was defined as occurrence of at least one of the following within 30 days of surgery; pneumonia, ileus, small bowel obstruction, urinary tract infection, surgical site infection, wound dehiscence, sepsis, anastomotic leak, arrhythmia and venous thromboembolism. Results: A total of 162 patients were identified with a mean age of 63 (34-88). 58 patients (36%) were female. Patient demographics, preoperative comorbidities, and operative details are summarized in the table. Mean FC withdrawal day was 8.8 days (1-65). 80 patients (49%) had early FC
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