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To What Extent Is Surgical Performance Influenced by Obesity in Single-Site Laparoscopic Colon and Rectal Surgery?
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Scientific Forum Abstracts
intervention. We report the results of our series of medical refractory severe acute IBD patients undergoing initial laparoscopic diverting loop ileostomy in place of colectomy. METHODS: From October 2013 to December 2014, 8 confirmed medical refractory IBD patients had single incision laparoscopic surgery (SILS) to create a diverting loop ileostomy, performed by the same attending at a university-based quaternary referral center. Data collected included demographics, Mayo or Harvey Bradshaw Index scores, and pre-, peri-, and postoperative assessments. RESULTS: All patients had severe colitis as determined by preoperative sigmoidoscopy and clinical severity scores. All operations were performed using SILS, with an average operating room time of 45 minutes. Fever, hemodynamics, and leukocytosis normalized within 24 hours of diversion, and patients tolerated po by postoperative day 2. The BMI and serum albumin improved within 3 months of diversion. There were no intraoperative, immediate, or 30-day postoperative complications or deaths. Three patients have had subsequent elective laparoscopic, hand-assisted total proctocolectomy with ileal pouch-anal anastomosis formation in the setting of improved nutrition and decreased overall immunosuppression without postoperative morbidity. CONCLUSIONS: Although this change in management strategy does not eliminate the potential need for definitive surgery, it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes. To What Extent Is Surgical Performance Influenced by Obesity in Single-Site Laparoscopic Colon and Rectal Surgery? Kristen T Crowell, MD, Joshua S Winder, MD, Matthew Z Wilson, MD, David B Stewart, MD, FACS, FASCRS, Evangelos Messaris, MD, PhD, FACS Pennsylvania State University College of Medicine, Hershey, PA
J Am Coll Surg
Conversion rate was 3-fold higher in obese patients (18.2% vs 6.8%; p¼0.016). Nine cases (69%) were converted due to obesity-related technical limitations. Operative time, blood loss, mortality, overall morbidity, and wound infections were not different in obese vs nonobese patients. A BMI>30 kg/m2 was an independent prognostic factor for conversion in a logistic regression analysis model (odds ratio 3, p¼0.015). CONCLUSIONS: Obesity increases conversion rate 3-fold without increasing other complications in this large series of SSL colorectal operations performed by experienced surgeons. Therefore, obese patients should be informed of the increased conversion risk or considered for alternative approaches such as standard laparoscopic or robotic. Transanal Minimally Invasive SurgerydReview of Indications and Outcomes in a Large Series Deborah S Keller, MD, Reena N Tahilramani, MD, Juan R Flores Gonzales, MD, Jaideep S Sandhu, MB, BS, Eric M Haas, MD, FACS, FASCRS Colorectal Surgical Associates, Houston, TX INTRODUCTION: There has been a paradigm shift in the management of low, early stage malignant and benign rectal lesions from radical resection to local excision. Transanal minimally invasive surgery (TAMIS) helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes in a large series of TAMIS cases. METHODS: Review of a prospective database identified patients who underwent TAMIS for resection from 2010-2014. Demographic, perioperative, short-term outcomes and recurrence data were analyzed.
METHODS: A retrospective review of consecutive patients undergoing SSL colon and rectal resections at a single institution between January 2012 and December 2014 was performed. Two colorectal surgeons had performed at least 100 SSL operations each before this study. Patient demographics, operative time, conversion to laparotomy, reason for conversion, mortality, and complications were recorded.
RESULTS: Seventy-five patients were analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m2 (SD 4.7 kg/m2). Median American Society of Anesthesiologists score was 2 (range 14). The main preoperative diagnoses were tubulovillous adenoma (40%), tubular adenoma (26.7%), and adenocarcinoma (22.7%). The median lesion distance from the anal verge was 10 cm (range 6-16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intra-peritoneal entry. All were successfully closed transanally. None of these developed recurrence. Nine had indeterminate or microscopically positive margins; 5 had TAMIS re-excision, 3 favored surveillance, and 1 underwent low anterior resection. The median length of stay was 0 days (range 0-1 day). Postoperatively, 3 developed complications (bleeding, rectal stricture, recto-vaginal fistula). All were managed nonoperatively. After median follow-up of 4.8 months (range 3-48 months), 5 patients developed local recurrence; 3 underwent repeat TAMIS re-excision, 1 underwent abdominoperineal resection, and 1 opted for surveillance.
RESULTS: A total of 213 patients underwent SSL resections; of these 66 (31%) had a BMI>30 kg/m2. Although obese patients had higher incidences of hypertension and diabetes (p<0.005), the distribution of comorbidities was similar between groups. Overall, conversion to laparotomy occurred in 22 cases (10.3%).
CONCLUSIONS: Transanal minimally invasive surgery is a viable option for benign or early stage rectal masses, with oncologic outcomes comparable to those with radical resection. Further, TAMIS minimizes morbidity and may allow more patients to benefit from the minimally invasive approach.
INTRODUCTION: Laparoscopic colon and rectal surgery in obese patients is safe but is associated with increased wound complications and intraoperative time. The effect of obesity on single-site laparoscopic (SSL) colon and rectal operations is unknown. This study investigated the impact of obesity on patient outcomes during SSL colorectal resections.
Scientific Forum Abstracts
intervention. We report the results of our series of medical refractory severe acute IBD patients undergoing initial laparoscopic diverting loop ileostomy in place of colectomy. METHODS: From October 2013 to December 2014, 8 confirmed medical refractory IBD patients had single incision laparoscopic surgery (SILS) to create a diverting loop ileostomy, performed by the same attending at a university-based quaternary referral center. Data collected included demographics, Mayo or Harvey Bradshaw Index scores, and pre-, peri-, and postoperative assessments. RESULTS: All patients had severe colitis as determined by preoperative sigmoidoscopy and clinical severity scores. All operations were performed using SILS, with an average operating room time of 45 minutes. Fever, hemodynamics, and leukocytosis normalized within 24 hours of diversion, and patients tolerated po by postoperative day 2. The BMI and serum albumin improved within 3 months of diversion. There were no intraoperative, immediate, or 30-day postoperative complications or deaths. Three patients have had subsequent elective laparoscopic, hand-assisted total proctocolectomy with ileal pouch-anal anastomosis formation in the setting of improved nutrition and decreased overall immunosuppression without postoperative morbidity. CONCLUSIONS: Although this change in management strategy does not eliminate the potential need for definitive surgery, it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes. To What Extent Is Surgical Performance Influenced by Obesity in Single-Site Laparoscopic Colon and Rectal Surgery? Kristen T Crowell, MD, Joshua S Winder, MD, Matthew Z Wilson, MD, David B Stewart, MD, FACS, FASCRS, Evangelos Messaris, MD, PhD, FACS Pennsylvania State University College of Medicine, Hershey, PA
J Am Coll Surg
Conversion rate was 3-fold higher in obese patients (18.2% vs 6.8%; p¼0.016). Nine cases (69%) were converted due to obesity-related technical limitations. Operative time, blood loss, mortality, overall morbidity, and wound infections were not different in obese vs nonobese patients. A BMI>30 kg/m2 was an independent prognostic factor for conversion in a logistic regression analysis model (odds ratio 3, p¼0.015). CONCLUSIONS: Obesity increases conversion rate 3-fold without increasing other complications in this large series of SSL colorectal operations performed by experienced surgeons. Therefore, obese patients should be informed of the increased conversion risk or considered for alternative approaches such as standard laparoscopic or robotic. Transanal Minimally Invasive SurgerydReview of Indications and Outcomes in a Large Series Deborah S Keller, MD, Reena N Tahilramani, MD, Juan R Flores Gonzales, MD, Jaideep S Sandhu, MB, BS, Eric M Haas, MD, FACS, FASCRS Colorectal Surgical Associates, Houston, TX INTRODUCTION: There has been a paradigm shift in the management of low, early stage malignant and benign rectal lesions from radical resection to local excision. Transanal minimally invasive surgery (TAMIS) helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes in a large series of TAMIS cases. METHODS: Review of a prospective database identified patients who underwent TAMIS for resection from 2010-2014. Demographic, perioperative, short-term outcomes and recurrence data were analyzed.
METHODS: A retrospective review of consecutive patients undergoing SSL colon and rectal resections at a single institution between January 2012 and December 2014 was performed. Two colorectal surgeons had performed at least 100 SSL operations each before this study. Patient demographics, operative time, conversion to laparotomy, reason for conversion, mortality, and complications were recorded.
RESULTS: Seventy-five patients were analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m2 (SD 4.7 kg/m2). Median American Society of Anesthesiologists score was 2 (range 14). The main preoperative diagnoses were tubulovillous adenoma (40%), tubular adenoma (26.7%), and adenocarcinoma (22.7%). The median lesion distance from the anal verge was 10 cm (range 6-16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intra-peritoneal entry. All were successfully closed transanally. None of these developed recurrence. Nine had indeterminate or microscopically positive margins; 5 had TAMIS re-excision, 3 favored surveillance, and 1 underwent low anterior resection. The median length of stay was 0 days (range 0-1 day). Postoperatively, 3 developed complications (bleeding, rectal stricture, recto-vaginal fistula). All were managed nonoperatively. After median follow-up of 4.8 months (range 3-48 months), 5 patients developed local recurrence; 3 underwent repeat TAMIS re-excision, 1 underwent abdominoperineal resection, and 1 opted for surveillance.
RESULTS: A total of 213 patients underwent SSL resections; of these 66 (31%) had a BMI>30 kg/m2. Although obese patients had higher incidences of hypertension and diabetes (p<0.005), the distribution of comorbidities was similar between groups. Overall, conversion to laparotomy occurred in 22 cases (10.3%).
CONCLUSIONS: Transanal minimally invasive surgery is a viable option for benign or early stage rectal masses, with oncologic outcomes comparable to those with radical resection. Further, TAMIS minimizes morbidity and may allow more patients to benefit from the minimally invasive approach.
INTRODUCTION: Laparoscopic colon and rectal surgery in obese patients is safe but is associated with increased wound complications and intraoperative time. The effect of obesity on single-site laparoscopic (SSL) colon and rectal operations is unknown. This study investigated the impact of obesity on patient outcomes during SSL colorectal resections.