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Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis reduces time to conceive
Vol. 221, No. 4S2, October 2015
with increased IgG4+PC and deeper infiltration, markers of severity did not correlate. Our results suggest that IgG4+PC may be a biomarker for active inflammation, however, larger sample size and prospective clinical correlation is necessary. Impact of an Enhanced Recovery after Surgery (ERAS) program on clinical outcomes and institutional costs in elective laparoscopic and open colorectal resections Carlo V Feo, MD, FACS, Mattia Portinari, MD, Simona S Ascanelli, MD, Simone Targa, MD, Elisabete Maria Dos Santos Valgode, RN, Barbara Bonvento, PhD, Emidia Vagnoni, PhD, Stefano Camerani, MD, Marco Verri, MD, Carlo Alberto Volta, MD S. Anna University Hospital of Ferrara, Ferrara, Italy; Univerity of Ferrara, Ferrara, Italy INTRODUCTION: To determine the impact on postoperative recovery and cost-effectiveness of a standardized ERAS colorectal program. METHODS: A prospective series of patients (N¼56) undergoing elective colorectal resection completing a standardized ERAS protocol in 2013-2014 (ERAS group) was compared to patients (N¼52) operated on at the same institution in 2011 (conventional group), before the introduction of ERAS methodology. The exclusion criteria for both groups were: age>80 years old, ASA score IV, TNM stage IV, and inflammatory bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and readmission rate in-between groups were compared. Direct costs related to the preoperative phase and hospitalization, and implementation of the ERAS program were collected. Data (median [IQR 25-75] or meanSD) were analyzed by intention to treat, using chi-square, t-Student, MannWhitney, and log-rank tests. Cox regression analysis identified independent predictors of prolonged hospital LOS. RESULTS: Gender and BMI were comparable between groups, while ERAS patients were slightly younger. Analyzing the last two tertiles a further decrease in hospital LOS was detected in the ERAS group [4 (4-6) vs 8 (7-10), P<0.001]. After adjusting for potential confounders, ASA score III (P¼0.012), and following a conventional perioperative protocol (P¼0.002) were independently predicted prolonged hospital LOS. CONCLUSIONS: Implementing an ERAS program in elective colorectal surgery significantly reduced time to functional recovery and postoperative hospital LOS; did not increase morbidity, mortality, and 30-day readmissions; and significantly decreased institutional costs. Study funded by the Italian Ministry of Health. Intestinal microperfusion patterns during colorectal resection: preliminary results of 34 patients Henry Hoffmann, MD, Tarik Delko, Marko Kraljevic, Juliane Scha¨fer, PhD, Christoph Kettelhack, MD University Hospital Basel, Basel, Switzerland INTRODUCTION: Ischemia at the anastomotic site is one of the most important risk factors for anastomotic leakage (AL).
Scientific Poster Presentations: 2015 Clinical Congress
e61
Therefore, unimpaired perfusion at the level of the capillary vessels (microperfusion) is essential for optimal oxygen supply and healing of the anastomosis. Intraoperative visual assessment of intestinal microperfusion has been found to be inefficient to predict AL. However, reliable intraoperative assessment of intestinal microvascular tissue oxygenation is not yet established. METHODS: Patients undergoing colorectal resection between July 2013 and December 2014 were prospectively recruited. Intraoperative microperfusion measurements were conducted using a Visible Light Spectroscope (VLS). Following measurements were performed at the colon serosa: Reference measurements at the caecum (M1) and proximal to planned resection (M2). After mobilization and vessel dissection: proximal (M3) and distal (M4) to the planned resection. After performing the anastomosis: 1-2cm proximal (M5) and distal (M6) to the anastomosis. RESULTS: Thirty-four patients with a median age of 72 years (interquartile range [IQR] 63; 80) were recruited. Main operations were laparoscopic sigmoidectomy (n¼13, 38%) and right hemicolectomy (n¼12, 35%). Median total duration of VLS measurement was 2:11 min (IQR 1:39; 3:55). The following median (IQR) serosal StO2 were observed: M1: 66% (57; 70), M2: 67% (60; 73), M3: 69% (60; 76), M4: 69% (55; 79), M5: 70% (63; 76), M6: 72% (62; 76). CONCLUSIONS: Intraoperative microperfusion measurement during colorectal resection using VLS seems feasible and time effective. Relative to the initial reference measurements (M1, M2), we observed an increase in StO2 and increasing variability after mobilization (M3, M4) and anastomosis (M5, M6). Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis reduces time to conceive Erman Aytac, Emre Gorgun, MD, FACS, Giovanna DaSilva, Jeffrey M Goldberg, MD, Luca Stocchi, MD, FACS, Steven D Wexner, MD, PhD (Hon), FACS, FRCS, FRCS(Ed), Feza H Remzi, MD, FACS, FASCRS Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Weston, FL INTRODUCTION: Females in the reproductive age comprise a significant percentage of patients undergoing ileal pouch-anal anastomosis (IPAA). Data regarding factors associated with female infertility and outcomes of pregnancy in patients with IPAA are limited. This study aims to evaluate female fertility, maternal, fetal and functional outcomes in patients with ileal pouch-anal anastomosis. METHODS: Female patients undergoing IPAA between 1983 and 2012 were sent a validated questionnaire to evaluate their reproductive function and pregnancy outcomes, both before and after surgery. Infertility was defined as 1 year of unprotected intercourse without conception. RESULTS: 523 patients with a mean age of 27 at diagnosis responded to the questionnaire. Mean follow up time was 19 years after diagnosis. Overall conception (77 vs 52 %, p<0.0001) and
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Scientific Poster Presentations: 2015 Clinical Congress
delivery (74 vs 47%, p<0.0001) rates significantly decreased after IPAA creation. Primary diagnosis had no impact on conception before or after IPAA creation (p¼0.265). Infertility was higher after IPAA creation (62 vs 37 %, p<0.0001). While conception was similar in patients following either open or laparoscopic IPAA (44 vs 54 %, respectively; p¼ 0.454), time to conceive was significantly shorter after laparoscopic surgery. IPAA related issues were urgency (5 %, 15 %, 30 %), incontinence (5%, 15 %, 21 %), pad usage (5 %, 13 %, 20 %) during first, second and third trimesters respectively. IPAA functions recovered within a mean time of 4 months after delivery. CONCLUSIONS: Laparoscopic and open IPAA comparably affect the ability to conceive. Among pregnant patients, laparoscopic IPAA is associated with a reduced time to conception. Laparoscopic vs open Hartmann’s reversal: a case-matched study Akin Onder, MD, Emre Gorgun, MD, FACS, Meagan M Costedio, MD, FACS, Hermann P Kessler, MD, PhD, FACS, Luca Stocchi, MD, FACS, Feza H Remzi, MD, FACS, FASCRS Cleveland Clinic, Cleveland, OH INTRODUCTION: Hartmann’s procedure remains the mainstay treatment for perforated, sigmoid diverticulitis. Hartmann’s reversal is a clinically demanding and associated a high rate of morbidity 3% 50% and mortality 1- 7.1%. The aim of this study is to compare short-term outcomes of laparoscopic vs open Hartmann’s reversal. METHODS: Patients who underwent Hartmann’s reversal between January 2005 and September 2014 were identified from a prospectively maintained database and matched for age, gender, body mass index and American Society of Anesthesiologists score to open counterparts. RESULTS: Eighteen patients with laparoscopic Hartmann’s reversal were matched to 18 open patients. There were no differences between laparoscopic vs open groups in operating times, (157.752.2 minutes vs 151.549.3 minutes, p¼0.52) or shortterm complication rates (p >0.99). However, the laparoscopic group was associated with significantly lower estimated blood loss (113.9102.5 cc vs 216.7124.9cc, p¼0.005), faster time to return of bowel function (3.240.6 days vs 4.00.65 days, p¼0.005), and shorter hospital stay (5.43.1days vs 8.34.8 days, p¼0.005). No anastomotic leaks or mortality occurred in either group. CONCLUSIONS: Laparoscopic Hartmann’s reversal can safely be performed with better short-term outcomes in carefully selected patients. Minimally invasive surgery for inflammatory bowel disease: nationwide evaluation of use and outcomes Deborah S Keller, MD, Reena N Tahilramani, MD, Nisreen Madhoun, DO, Juan R Flores-Gonzalez, MD, Sergio H Ibarra, MD, Jaideep S Sandhu, MB, BS, Lisa M Haubert, MD, Eric M Haas, MD, FACS, FASCRS
J Am Coll Surg
Colorectal Surgical Associates, University of Texas Medical School at Houston, Houston, TX INTRODUCTION: The benefits of laparoscopic colorectal surgery continue to develop, and the platform is being increasingly used. However, concerns about the learning curve and safety in inflammatory bowel disease (IBD) remain. Our goal was to evaluate the current use and outcomes for laparoscopy in IBD. METHODS: Review of a prospective national inpatient database identified patients undergoing elective abdominal surgery for IBD from 2008-2011. Patients were stratified by laparoscopic (LAP) or open (OPEN) approach. Stoma closures were excluded. Demographic, procedural, and postoperative outcomes were evaluated. The main outcome measures were the total hospital costs, complications, length of stay (LOS), readmission and mortality rates. RESULTS: 1,472 cases were evaluated: 32% LAP and 68% open. Over the study period, LAP use significantly increased each year, with corresponding declines in OPEN (p¼0.05). The distribution of Crohn’s disease (p¼0.92), ulcerative colitis (p¼0.31), and indeterminate colitis (p¼0.43) was similar across cohorts. Most patients had moderate comorbidities (49.89% LAP, 45.25% OPEN), where rates of LAP and OPEN were comparable (p¼0.0962). There were higher LAP rates in patients with lower comorbidities (p<.0001), and higher OPEN rates in patients with higher comorbidities (p<.0001). The conversion rate was 18.90%. LAP patients had significantly shorter LOS (p<.0001) and lower complication (p<.0001), readmission (p¼.0294), and mortality rates (p¼0.0045). LAP also had significantly lower total costs than OPEN (p<.0001). CONCLUSIONS: Despite proven efficacy, laparoscopy remains underutilized in IBD. Our study further illustrated the patient benefits with laparoscopy. In addition, we demonstrate that laparoscopy lowered total costs for IBD surgery. Conversion did not impact patient or financial outcomes. The laparoscopic approach should be expanded to optimize efficiency and quality in IBD patients.
Multispecialty robotic surgery: a team approach Jacquelyn M Charbel, Amir L Bastawrous, MD, MBA Swedish Medical Center, Seattle, WA INTRODUCTION: Compared to other specialties, robotics has been slow to adoption among colorectal surgeons. The learning curve, immaturity of outcome data, and relative lack of availability of the robotic system have been hindrances to its acceptance. However, one rationale rarely sited as a reason to learn robotic surgery is the necessity of multispecialty robotic surgeons. METHODS: We conducted a retrospective review of robotic cases performed by colorectal surgeons at Swedish Medical Centers. We reviewed the indications and incidences around which colorectal surgeons performed robotic procedures jointly with other robotic specialties.
with increased IgG4+PC and deeper infiltration, markers of severity did not correlate. Our results suggest that IgG4+PC may be a biomarker for active inflammation, however, larger sample size and prospective clinical correlation is necessary. Impact of an Enhanced Recovery after Surgery (ERAS) program on clinical outcomes and institutional costs in elective laparoscopic and open colorectal resections Carlo V Feo, MD, FACS, Mattia Portinari, MD, Simona S Ascanelli, MD, Simone Targa, MD, Elisabete Maria Dos Santos Valgode, RN, Barbara Bonvento, PhD, Emidia Vagnoni, PhD, Stefano Camerani, MD, Marco Verri, MD, Carlo Alberto Volta, MD S. Anna University Hospital of Ferrara, Ferrara, Italy; Univerity of Ferrara, Ferrara, Italy INTRODUCTION: To determine the impact on postoperative recovery and cost-effectiveness of a standardized ERAS colorectal program. METHODS: A prospective series of patients (N¼56) undergoing elective colorectal resection completing a standardized ERAS protocol in 2013-2014 (ERAS group) was compared to patients (N¼52) operated on at the same institution in 2011 (conventional group), before the introduction of ERAS methodology. The exclusion criteria for both groups were: age>80 years old, ASA score IV, TNM stage IV, and inflammatory bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and readmission rate in-between groups were compared. Direct costs related to the preoperative phase and hospitalization, and implementation of the ERAS program were collected. Data (median [IQR 25-75] or meanSD) were analyzed by intention to treat, using chi-square, t-Student, MannWhitney, and log-rank tests. Cox regression analysis identified independent predictors of prolonged hospital LOS. RESULTS: Gender and BMI were comparable between groups, while ERAS patients were slightly younger. Analyzing the last two tertiles a further decrease in hospital LOS was detected in the ERAS group [4 (4-6) vs 8 (7-10), P<0.001]. After adjusting for potential confounders, ASA score III (P¼0.012), and following a conventional perioperative protocol (P¼0.002) were independently predicted prolonged hospital LOS. CONCLUSIONS: Implementing an ERAS program in elective colorectal surgery significantly reduced time to functional recovery and postoperative hospital LOS; did not increase morbidity, mortality, and 30-day readmissions; and significantly decreased institutional costs. Study funded by the Italian Ministry of Health. Intestinal microperfusion patterns during colorectal resection: preliminary results of 34 patients Henry Hoffmann, MD, Tarik Delko, Marko Kraljevic, Juliane Scha¨fer, PhD, Christoph Kettelhack, MD University Hospital Basel, Basel, Switzerland INTRODUCTION: Ischemia at the anastomotic site is one of the most important risk factors for anastomotic leakage (AL).
Scientific Poster Presentations: 2015 Clinical Congress
e61
Therefore, unimpaired perfusion at the level of the capillary vessels (microperfusion) is essential for optimal oxygen supply and healing of the anastomosis. Intraoperative visual assessment of intestinal microperfusion has been found to be inefficient to predict AL. However, reliable intraoperative assessment of intestinal microvascular tissue oxygenation is not yet established. METHODS: Patients undergoing colorectal resection between July 2013 and December 2014 were prospectively recruited. Intraoperative microperfusion measurements were conducted using a Visible Light Spectroscope (VLS). Following measurements were performed at the colon serosa: Reference measurements at the caecum (M1) and proximal to planned resection (M2). After mobilization and vessel dissection: proximal (M3) and distal (M4) to the planned resection. After performing the anastomosis: 1-2cm proximal (M5) and distal (M6) to the anastomosis. RESULTS: Thirty-four patients with a median age of 72 years (interquartile range [IQR] 63; 80) were recruited. Main operations were laparoscopic sigmoidectomy (n¼13, 38%) and right hemicolectomy (n¼12, 35%). Median total duration of VLS measurement was 2:11 min (IQR 1:39; 3:55). The following median (IQR) serosal StO2 were observed: M1: 66% (57; 70), M2: 67% (60; 73), M3: 69% (60; 76), M4: 69% (55; 79), M5: 70% (63; 76), M6: 72% (62; 76). CONCLUSIONS: Intraoperative microperfusion measurement during colorectal resection using VLS seems feasible and time effective. Relative to the initial reference measurements (M1, M2), we observed an increase in StO2 and increasing variability after mobilization (M3, M4) and anastomosis (M5, M6). Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis reduces time to conceive Erman Aytac, Emre Gorgun, MD, FACS, Giovanna DaSilva, Jeffrey M Goldberg, MD, Luca Stocchi, MD, FACS, Steven D Wexner, MD, PhD (Hon), FACS, FRCS, FRCS(Ed), Feza H Remzi, MD, FACS, FASCRS Cleveland Clinic, Cleveland, OH; Cleveland Clinic, Weston, FL INTRODUCTION: Females in the reproductive age comprise a significant percentage of patients undergoing ileal pouch-anal anastomosis (IPAA). Data regarding factors associated with female infertility and outcomes of pregnancy in patients with IPAA are limited. This study aims to evaluate female fertility, maternal, fetal and functional outcomes in patients with ileal pouch-anal anastomosis. METHODS: Female patients undergoing IPAA between 1983 and 2012 were sent a validated questionnaire to evaluate their reproductive function and pregnancy outcomes, both before and after surgery. Infertility was defined as 1 year of unprotected intercourse without conception. RESULTS: 523 patients with a mean age of 27 at diagnosis responded to the questionnaire. Mean follow up time was 19 years after diagnosis. Overall conception (77 vs 52 %, p<0.0001) and
e62
Scientific Poster Presentations: 2015 Clinical Congress
delivery (74 vs 47%, p<0.0001) rates significantly decreased after IPAA creation. Primary diagnosis had no impact on conception before or after IPAA creation (p¼0.265). Infertility was higher after IPAA creation (62 vs 37 %, p<0.0001). While conception was similar in patients following either open or laparoscopic IPAA (44 vs 54 %, respectively; p¼ 0.454), time to conceive was significantly shorter after laparoscopic surgery. IPAA related issues were urgency (5 %, 15 %, 30 %), incontinence (5%, 15 %, 21 %), pad usage (5 %, 13 %, 20 %) during first, second and third trimesters respectively. IPAA functions recovered within a mean time of 4 months after delivery. CONCLUSIONS: Laparoscopic and open IPAA comparably affect the ability to conceive. Among pregnant patients, laparoscopic IPAA is associated with a reduced time to conception. Laparoscopic vs open Hartmann’s reversal: a case-matched study Akin Onder, MD, Emre Gorgun, MD, FACS, Meagan M Costedio, MD, FACS, Hermann P Kessler, MD, PhD, FACS, Luca Stocchi, MD, FACS, Feza H Remzi, MD, FACS, FASCRS Cleveland Clinic, Cleveland, OH INTRODUCTION: Hartmann’s procedure remains the mainstay treatment for perforated, sigmoid diverticulitis. Hartmann’s reversal is a clinically demanding and associated a high rate of morbidity 3% 50% and mortality 1- 7.1%. The aim of this study is to compare short-term outcomes of laparoscopic vs open Hartmann’s reversal. METHODS: Patients who underwent Hartmann’s reversal between January 2005 and September 2014 were identified from a prospectively maintained database and matched for age, gender, body mass index and American Society of Anesthesiologists score to open counterparts. RESULTS: Eighteen patients with laparoscopic Hartmann’s reversal were matched to 18 open patients. There were no differences between laparoscopic vs open groups in operating times, (157.752.2 minutes vs 151.549.3 minutes, p¼0.52) or shortterm complication rates (p >0.99). However, the laparoscopic group was associated with significantly lower estimated blood loss (113.9102.5 cc vs 216.7124.9cc, p¼0.005), faster time to return of bowel function (3.240.6 days vs 4.00.65 days, p¼0.005), and shorter hospital stay (5.43.1days vs 8.34.8 days, p¼0.005). No anastomotic leaks or mortality occurred in either group. CONCLUSIONS: Laparoscopic Hartmann’s reversal can safely be performed with better short-term outcomes in carefully selected patients. Minimally invasive surgery for inflammatory bowel disease: nationwide evaluation of use and outcomes Deborah S Keller, MD, Reena N Tahilramani, MD, Nisreen Madhoun, DO, Juan R Flores-Gonzalez, MD, Sergio H Ibarra, MD, Jaideep S Sandhu, MB, BS, Lisa M Haubert, MD, Eric M Haas, MD, FACS, FASCRS
J Am Coll Surg
Colorectal Surgical Associates, University of Texas Medical School at Houston, Houston, TX INTRODUCTION: The benefits of laparoscopic colorectal surgery continue to develop, and the platform is being increasingly used. However, concerns about the learning curve and safety in inflammatory bowel disease (IBD) remain. Our goal was to evaluate the current use and outcomes for laparoscopy in IBD. METHODS: Review of a prospective national inpatient database identified patients undergoing elective abdominal surgery for IBD from 2008-2011. Patients were stratified by laparoscopic (LAP) or open (OPEN) approach. Stoma closures were excluded. Demographic, procedural, and postoperative outcomes were evaluated. The main outcome measures were the total hospital costs, complications, length of stay (LOS), readmission and mortality rates. RESULTS: 1,472 cases were evaluated: 32% LAP and 68% open. Over the study period, LAP use significantly increased each year, with corresponding declines in OPEN (p¼0.05). The distribution of Crohn’s disease (p¼0.92), ulcerative colitis (p¼0.31), and indeterminate colitis (p¼0.43) was similar across cohorts. Most patients had moderate comorbidities (49.89% LAP, 45.25% OPEN), where rates of LAP and OPEN were comparable (p¼0.0962). There were higher LAP rates in patients with lower comorbidities (p<.0001), and higher OPEN rates in patients with higher comorbidities (p<.0001). The conversion rate was 18.90%. LAP patients had significantly shorter LOS (p<.0001) and lower complication (p<.0001), readmission (p¼.0294), and mortality rates (p¼0.0045). LAP also had significantly lower total costs than OPEN (p<.0001). CONCLUSIONS: Despite proven efficacy, laparoscopy remains underutilized in IBD. Our study further illustrated the patient benefits with laparoscopy. In addition, we demonstrate that laparoscopy lowered total costs for IBD surgery. Conversion did not impact patient or financial outcomes. The laparoscopic approach should be expanded to optimize efficiency and quality in IBD patients.
Multispecialty robotic surgery: a team approach Jacquelyn M Charbel, Amir L Bastawrous, MD, MBA Swedish Medical Center, Seattle, WA INTRODUCTION: Compared to other specialties, robotics has been slow to adoption among colorectal surgeons. The learning curve, immaturity of outcome data, and relative lack of availability of the robotic system have been hindrances to its acceptance. However, one rationale rarely sited as a reason to learn robotic surgery is the necessity of multispecialty robotic surgeons. METHODS: We conducted a retrospective review of robotic cases performed by colorectal surgeons at Swedish Medical Centers. We reviewed the indications and incidences around which colorectal surgeons performed robotic procedures jointly with other robotic specialties.