Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study of anastomotic complications.

PURPOSE: Laparoscopic right hemicolectomy (LRH) can be performed with an intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA). It is not clear which technique is best. This study evaluated the impact of each anastomosis technique on perioperative safety and postoperative evolution. METHODS: We performed a retrospective study at a tertiary colorectal surgery center. All patients who had an elective LRH from 2015 to 2019 were analyzed according to the anastomosis technique used. RESULTS: In total, 285 patients were included in the study. IA was performed in 64 patients (22.5%). Mean operative time was longer in the patients with IA (IA, 160±31 minutes vs. EA, 138±42 minutes; P<0.001). No differences were observed in intraoperative complications, time to first bowel movement, length of stay, reoperation, or rehospitalization. Time to first flatus was longer in the patients with IA (P=0.049). At 30 days after surgery, there were no differences in the frequency of anastomotic leak (IA, 0% vs. EA, 2.3%; P=0.59), bleeding (IA, 3.1% vs. EA, 2.7%; P>0.99), or intraabdominal abscess (IA, 0% vs. EA, 0.5%; P>0.99). During follow-up, we noted more incisional hernias in patients with EA (IA, 1.6% vs. EA, 11.3%; P=0.01) and a trend toward more hernia in patients with EA in multivariate analysis (hazard ratio, 7.13; P=0.06). Anastomosis technique had no influence on recurrence. CONCLUSION: For LRH, both IA and EA are safe, with a low incidence of complications when performed by experienced surgeons. IA may be associated with a lower incidence of incisional hernia.

Prophylactic retromuscular mesh placement for parastomal hernia prevention: a retrospective cohort study of permanent colostomies and ileostomies.

PURPOSE: Parastomal hernia (PSH) is the most common complication of stoma formation. The safety and efficiency of prophylactically placing mesh to prevent PSH remain controversial. To address this question, we examined the incidence of clinical and radiological PSH when using parastomal prophylactic mesh (PPM). METHODS: We performed a retrospective, single-center, cohort study that included all patients with permanent stoma creation between 2015 and 2018. Patients were divided into two groups according to the utilization of PPM or not. RESULTS: During the study period, 185 patients had a permanent stoma created, 144 with colostomy and 41 with ileostomy. PPM was placed in 79 patients. There was no difference in the need for early surgical reintervention (p = 0.652) or rehospitalization (p = 0.314) for stoma-related complications in patients with mesh as compared with patients without. Similarly, there was no difference in operative time (p = 0.782) or in length of hospital stay (p = 0.806). No patients experienced infection of the mesh or required prosthesis removal. There was a lower incidence rate of PSH with PPM placement in patients with permanent colostomy [adjusted hazard ratio (HR) 0.50 (95% confidence interval 0.28-0.89); p = 0.018]. In contrast, a higher incidence rate of PSH was observed in patients with ileostomy and PPM [adjusted HR 5.92 (95% confidence interval 1.07-32.65); p = 0.041]. CONCLUSION: Parastomal prophylactic mesh placement to prevent PSH is a safe and efficient approach to reduce the incidence of PSH in patients requiring a permanent colostomy. However, mesh may increase the rate of PSH after permanent ileostomy.

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period.

BACKGROUND: Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era. METHODS: We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS. RESULTS: Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028). CONCLUSION: From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study.

BACKGROUND: We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission. METHODS: Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality. RESULTS: From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs. 32.6%; P = .02), time to oral intake shorter (3 vs. 6 days; P < .01), and LOS shorter (5 vs. 8 days; P = .05) for LCR. CONCLUSIONS: In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.

Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option.

BACKGROUND: Anastomotic leaks after low anterior resection for rectal cancer remain a major cause of morbidity and mortality. Few studies have focused on their management, particularly on the technique of transanal drainage. OBJECTIVE: The aim of this study was to assess the short- and long-term outcomes according to the initial management of clinical leaks. DESIGN AND SETTINGS: This study is a retrospective review of a single institution experience. PATIENTS: All patients treated for a symptomatic anastomotic leak after low anterior resection for rectal cancer between January 2000 and March 2011 were included. MAIN OUTCOME MEASURES: The primary outcomes were mortality attributed to the leak, sepsis control, stoma closure rate, and functional results. RESULTS: A total of 37 patients (35 men/2 women) developed a symptomatic leak. Leaks were initially managed by transanal drainage in 16 patients, abdominal reintervention in 12 patients, and medical treatment in 9 patients. The only death attributed to the leak occurred in the abdominal reintervention group. In the transanal drainage group, antibiotics were administered for a median length of 9 days, and the drain was left in place for a median length of 30 days. One patient underwent percutaneous drainage of a collection in addition to transanal drainage, but no patient required abdominal reintervention. Of the treatment modalities applied, transanal drainage was associated with the highest stoma closure rate (93%), after a median postoperative time of 7 months. Complications observed after transanal drainage were anastomotic strictures in 33% and the creation of a permanent stoma due to poor function in 13%. LIMITATIONS: This study was limited by its nonrandomized retrospective design and the presence of selection bias. CONCLUSIONS: : For the management of low anastomotic leaks, transanal drainage allows preservation of the anastomosis and sepsis control with a high rate of ileostomy closure. It is a valuable option in patients with a diverting ileostomy.