Staging and surgical approaches in gastric cancer: a clinical practice guideline.

BACKGROUND: Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer. METHODS: Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed. RESULTS: One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented. CONCLUSIONS: All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

Laparoscopy influences hiring practices within academic surgical departments.

BACKGROUND: This study aimed to determine whether the increasing emphasis on minimally invasive surgery (MIS) influences hiring practices within academic surgical departments. METHODS: A questionnaire was mailed to chairs of surgery departments and divisions of general surgery at the 16 Canadian academic institutions. Nonresponders were identified and contacted directly. The survey consisted of 34 questions, including Likert scales, single answers, and multiple-choice questions. Data were collected on demographics, perceptions of MIS, and recruitment/hiring. At the time of the survey, two department chair positions were vacant. RESULTS: A response rate of 87% (26/30) was obtained, with representation from 94% of departments (15/16). Of those surveyed, 88% intend to increase the importance of MIS at their institution within 5 years, and 87% intend to achieve this objective through new hirings. Networking (73%) and retention of recent graduates (89%) were cited most frequently as recruitment strategies. Strengthening the division, research, and education were considered important or extremely important by more than 90% of the respondents with respect to recruitment goals, whereas strengthening MIS was considered important or extremely important by 50%. Within 5 years, surgical departments intend to hire a median of four general surgeons, 50% of whom will have formal MIS training. In comparison, over the past 10 years, only 25% of new recruits had formal MIS training. More than 90% of the respondents considered formal MIS fellowship, MIS fellowship plus a second fellowship, and proctorship to be adequate training for performing advanced MIS, whereas traditional methods were considered inadequate. Lack of operative time and resource issues were considered most limiting in the hiring of new MIS surgeons. CONCLUSION: Minimally invasive surgery is growing in importance within academic surgical departments, but it remains an intermediate recruitment priority. Formal MIS training appears to be important in the recruiting of new surgeons, whereas traditional training methods are considered inadequate.

Laparoscopic resection for colon cancer: would all patients benefit?

PURPOSE: This study was designed to assess whether the exclusion criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials affected the generalizability of their findings. METHODS: A prospective database of consecutive laparoscopic resections performed for colon cancer was reviewed. Patients were categorized into two groups: inclusion group and exclusion group, based on the selection criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials. Baseline and perioperative data were analyzed by using t-tests, Wilcoxon's rank-sum, chi-squared, and Fisher's exact test. Kaplan-Meier survival curves, followed by adjustment for tumor nodes metastasis stage and age utilizing a Cox proportional hazard model, were performed. RESULTS: The inclusion group had 221 patients and the exclusion group had 166 (median age and gender distribution were similar). The exclusion group had a higher conversion rate (23 vs. 11.3 percent; P=0.0023). There was no difference in intraoperative complications (9 percent for exclusion group vs. 8.6 percent for inclusion group; P=0.8), operative time (180 minutes for exclusion group vs.172 minutes for inclusion group; P=0.24), or postoperative complication rates (33.7 percent for exclusion group vs. 26 percent for inclusion group; P=0.13). No difference was detected in perioperative mortality rates, length of stay, days to diet as tolerated, and adjusted two-year survival. CONCLUSIONS: No differences were found in outcomes between the two groups in terms of operative/postoperative complications, length of stay, perioperative mortality, and two-year survival. It seems that all patients with colon cancer can potentially benefit from a laparoscopic approach.

Broad-based fellowships: a cornerstone of minimally invasive surgery education and dissemination.

Aware of the trends in surgery and of public demand, many residents completing a 5-year training program seek fellowships in minimally invasive surgery (MIS) because of inadequate exposure to advanced MIS during their residency. A survey was designed to evaluate the effectiveness of a broad-based fellowship in advanced laparoscopic surgery offered in an academic health science center. The questionnaire was mailed to all graduates. Data on demographics, comfort level with specific laparoscopic procedures, and opinions regarding the best methods of acquiring these skills were collected. Most of the surgeons entered the fellowship directly after residency. The majority of these surgeons are academic surgeons. Fellows performed a median of 187 cases by the end of their training and felt comfortable operating on foregut, hindgut, and end organ. A full year of training was found to be the best format for appropriate skill transfer. A broad-based MIS fellowship meets the needs of both academic and community surgeons desiring to perform advanced laparoscopic procedures.

Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous ketorolac on length of hospital stay.

BACKGROUND: The objective of this study was to determine if intravenous ketorolac can reduce ileus following laparoscopic colorectal surgery, thus shortening hospital stay. METHODS: This was a prospective, randomized, double-blind, placebo-controlled, clinical trial of patients undergoing laparoscopic colorectal resection and receiving morphine patient controlled analgesia (PCA) and either intravenous ketorolac (group A) or placebo (group B), for 48 h after surgery. Daily assessments were made by a blinded assistant for level of pain control. Diet advancement and discharge were decided according to strictly defined criteria. RESULTS: From October 2002 to March 2005, 190 patients underwent laparoscopic colorectal surgery. Of this total, 84 patients were eligible for this study and 70 consented. Another 26 patients were excluded, leaving 22 patients in each group. Two patients who suffered anastomotic leaks in the early postoperative period were excluded from further analysis. Median length of stay for the entire study was 4.0 days, with significant correlation between milligrams of morphine consumed and time to first flatus (r = 0.422, p = 0.005), full diet (r = 0.522, p < 0.001), and discharge (r = 0.437, p = 0.004). There we no differences between groups in age, body mass index, or operating time. Patients in group A consumed less morphine (33 +/- 31 mg versus 63 +/- 41 mg, p = 0.011), and had less time to first flatus (median 2.0 days versus 3.0 days, p < 0.001) and full diet (median 2.5 days versus 3.0 days, p = 0.033). The reduction in length of stay was not significant (mean 3.6 days versus 4.5 days, median 4.0 days versus 4.0 days, p = 0.142). Pain control was superior in group A. Three patients required readmission for treatment of five anastomotic leaks (4 in group A versus 1 in group B, p = 0.15). Two of them underwent reoperation. CONCLUSIONS: Intravenous ketorolac was efficacious in improving pain control and reducing postoperative ileus when anastomotic leaks were excluded. This simple intervention shows promise in reducing hospital stay, although the outcome was not statistically significant. The high number of leaks is inconsistent with this group's experience and is of concern.

Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal.

BACKGROUND: Laparoscopic resection has become an accepted approach to gastrointestinal stromal tumors (GISTs), with acceptable early results published in the literature. Long-term recurrence rates, however, are still unclear, and the management of tumors in challenging locations requires exploration. METHODS: A retrospective analysis of all patients undergoing a laparoscopic resection of gastric GIST in our institution between November 1997 and July 2004 was performed. RESULTS: A total of 14 patients with 15 tumors were evaluated, 5 of which were located high on the lesser curve. All the patients had an attempted laparoscopic approach, with the following procedures performed: stapled wedge excision (n = 8), excision and manual sewing technique (n = 4), and distal gastrectomy (n = 1). Overall, there was a 15% (n = 2) conversion rate. Lesions found in the fundus and greater curvature areas were easily resected via simple stapled wedge excision. High lesser curve tumors were more difficult to manage and required a combination of methods for complete excision and preservation of the gastrointestinal junction including intraoperative gastroscopy, excision and manual sewing technique, and reconstruction over an esophageal bougie. There were no postoperative complications, and the length of hospital stay was 4.6 +/- 1.9 days. At a median follow-up period of 46.5 months (mean, 37.4 +/- 26 months), one patient experienced a recurrence (18 months postoperatively), with eventual disease-related death. CONCLUSION: The laparoscopic approach to gastric GIST tumors is safe and associated with acceptable short- and intermediate-term results. High lesser curve GISTs can be safely approached laparoscopically using various techniques to ensure an adequate resection margin without compromise of the GE junction.

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required.

BACKGROUND: Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed. METHODS: A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy. RESULTS: Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux). CONCLUSION: Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.

Laparoscopic resections for colorectal cancer: does conversion survival?

BACKGROUND: This purpose of this study was to examine whether survival is affected when laparoscopic resections for colorectal cancer are converted to open surgery. METHODS: A prospective database of 377 consecutive laparoscopic resections for colorectal cancer performed between November 1991 and June 2002 was reviewed. The TNM classification for colorectal cancer and the Kaplan-Meier method were used to determine survival curves for each group. RESULTS: Conversion to an open procedure was required in 46 cases (12.8%). Converted and laparoscopic groups were similar in age, sex, comorbidities, and location and size of tumor. The converted group had a significantly higher weight (75 kg vs 69 kg, p = 0.013) and conversion score (2.18 vs. 1.87, p = 0.005). Patients with stage IV disease were significantly more likely to be converted than those with stage I-III disease (23.0% vs 11.2%, p = 0.04). There was no difference in the conversion rate between patients with stage I (14%), II (8%), or III (13%) colorectal cancers. Median follow-up was 30.5 months for stage I-III and 10.8 months for stage IV cancers. There were 190 patients followed at least 2 years and 73 patients followed at least 5 years. Survival curves demonstrate significantly lower 2-year survival after converted procedures as compared to laparoscopic (75.7% vs 87.2%, p = 0.02), with a trend toward lower 5-year survival (61.9% vs 69.7%, p = 0.077). CONCLUSIONS: Survival rates at 2 and 5 years are lower for patients in the converted group compared to patients with LR. This finding could have serious impact on the treatment of patients with colorectal cancer. Further confirmation is required.

Laparoscopic nephrectomy for autosomal dominant polycystic kidney disease.

BACKGROUND: The authors reviewed their experience with laparoscopic nephrectomy for autosomal dominant polycystic kidney disease to evaluate whether patient-related or surgery-related factors influence operative outcomes. METHODS: A retrospective review was carried out of 22 consecutive laparoscopic nephrectomies performed by one surgeon in a university setting between March 1998 and March 2003. The impact of patient factors (body mass index, preoperative hemoglobin level, preoperative blood urea nitrogen and creatinine, kidney size and side, prior abdominal surgery, dialysis) and surgical factors (surgeon experience and preoperative embolization) on short-term outcomes (estimated blood loss, transfusion requirements, operative time, conversion, intra- and postoperative complications and length of stay) was analyzed using the Student's t-test, Pearson correlation, and Mann-Whitney and Fisher tests. RESULTS: A total of 19 patients underwent 22 nephrectomies. The average patient age was 49 years (range, 36-65 years) and the average body mass index was 31.4 kg/m2 (range, 20.4-64.5 kg/m2). Fourteen patients (68%) were receiving dialysis. Fifteen right (68%) and 7 left (32%) nephrectomies were performed. The median kidney size was 22 cm (range, 8-50 cm). Five patients (23%) had preoperative embolization. The median operative time was 255 min (range, 95-415 min). There were no mortalities. The intraoperative complication rate was 18% (1 vena cava laceration, 1 cecal perforation, 1 dialysis fistula thrombosis, 1 intrarenal bleeding requiring conversion), and the postoperative complication rate was 32% (1 myocardial infarction, 1 urgent laparotomy for clinical peritonitis, 1 minor bile fistula, 1 AV fistula thrombosis, 2 incisional hernias, 1 urinary retention). Four procedures (18%) were converted (1 for vena cava laceration, 1 for cecal perforation, 1 for intrarenal bleeding, 1 for adhesions). The median blood loss was 400 ml (range, 100-5000 ml). Eight patients (36%) received transfusions (median, 2 units). The median length of stay was 4 days. The patients who required blood transfusions had lower preoperative hemoglobin levels. Preoperative embolization did not affect surgical outcome. However, surgeon experience significantly reduced operative time. CONCLUSIONS: Laparoscopic nephrectomy for autosomal dominant polycystic kidney disease is a safe procedure, providing patients with a short hospital stay. Complication and conversion rates are relatively high.

Toward reliable operative assessment: the reliability and feasibility of videotaped assessment of laparoscopic technical skills.

BACKGROUND: Decision making on the competency of surgical trainees to perform laparoscopic procedures has been hampered by the lack of reliable methods to evaluate operative performance. The goal of this study was to develop a feasible and reliable method of evaluation. METHODS: Twenty-nine senior surgical residents were videotaped performing a low anterior resection and a Nissen fundoplication in a pig. Ten blinded laparoscopists rated the videos independently on two scales. Rating time was minimized by allowing raters to fast-forward through the tapes at their discretion. Interrater reliability and the time required to rate a procedure were assessed. RESULTS: Rating time per procedure was a median of 15 min (range, 6-40). The mean interrater reliability for the two scales was 0.74. CONCLUSIONS: The use of videotapes of operations enabled multiple raters to assess a performance reliably and shortened assessment times by 80%. This assessment technique shows potential as a means of evaluating the performance of advanced laparoscopic procedures by surgical trainees.

Predicting conversion in laparoscopic colorectal surgery. Fellowship training may be an advantage.

BACKGROUND: Laparoscopic colorectal surgery has clear advantages over open surgery; however, the effectiveness of the approach depends on the conversion rate. The objective of this work was to prospectively validate a model that would predict conversion in laparoscopic colorectal surgery. METHODS: A simple clinical model for predicting conversion in laparoscopic colorectal surgery was previously developed based on a multivariable logistic regression analysis of 367 procedures. This model was applied prospectively to a follow-up group of 248 procedures by the same team, including 54 procedures performed by one new fellowship-trained surgeon. RESULTS: Patients in the follow-up group were more likely to have cancer (56% vs 44%, p = 0.007) and were more obese (median, 71.0 vs 66.0 kg; p < 0.001). The rate of conversion in the follow-up group was unchanged (8.9% vs 9.0%, p > 0.05). Despite expected trends toward increasing risk of conversion with weight level (<60 kg, 6.8%; 60-<90 kg, 9.0%; >90 kg, 12.1%; p > 0.05) and malignancy (10.1% vs 7.3%, p > 0.05), the model did not distinguish well between groups at risk for conversion. Contrary to the model, however, the fellowship-trained surgeon had a conversion rate that was not higher than that of the other, more experienced surgeons (7.3% vs 9.3%, p > 0.05) even though he was less experienced, and operating on patients who were more obese (median, 75.0 vs 70 kg; p = 0.02) and more likely to have cancer (59% vs 55%, p > 0.05). Recalculated conversion scores that excluded the inexperience point for the fellowship-trained surgeon showed a good fit for the model. Considering the original and follow-up experience together (615 cases), the model clearly stratifies patients into low (0 points), medium (1-2 points), and high risk (3-4 points) for conversion, with respective rates of 2.9%, 8.1%, and 20% ( p = 0.001). CONCLUSION: This model appears to be a valid predictor of conversion to open surgery. Fellowship training may provide sufficient experience so that learning curve issues are redundant in early practice. This model now requires validation by other centers.

"Needlescopic" heller myotomy.

MIS continues to evolve with the introduction of new techniques and technology. This report discusses the use of "needlescopic" technology in the surgical management of achalasia. Heller myotomy procedures performed between January 1, 1997, and July 1, 2000, were analyzed and the results of 14 needlescopic procedures were compared with 15 laparoscopic procedures. Demographic and short-term outcome data were compared for each group using chi2, Fisher exact, and Student t tests where appropriate. Both groups were similar in age and gender. However, the needlescopic group weighed less (72.2 vs. 83.5 kg; P = 0.05). Intraoperatively, the needlescopic procedures were shorter (98.2 vs. 131.9 minutes; P = 0.03). There were no conversions to open surgery or differences in the number of intraoperative complications for either group. Postoperatively, the groups had similar complications, time to normal diet, and analgesia requirements. Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs. 2.0 days; P = 0.04). Needlescopic Heller myotomy appears to be a safe treatment option, resulting in a decreased length of stay and improved wound cosmesis.

Minimally invasive surgery training in Canada: a survey of general surgery.

BACKGROUND: The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. METHODS: A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. RESULTS: Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). CONCLUSION: The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Laparoscopic versus open donor nephrectomy.

BACKGROUND: As compared with open donor nephrectomy (OpenDN), laparoscopic donor nephrectomy (LapDN) offers donors more rapid recovery and recipients equivalent graft function, but LapDN costs remain greater. This study compared LapDN and OpenDN with cost-utility analysis. METHODS: Utilities were assessed with time trade-off, probabilities derived from systematic review of the literature and the costs derived from 27 OpenDN and 34 LapDN patients treated contemporaneously. A societal perspective was taken. Lost employment costs were included. An incremental cost-effectiveness ratio (ICER) was calculated with best- and worst-case scenarios for confidence intervals. Sensitivity analyses assessed robustness. RESULTS: LapDN costs are lower (11,170.71 dollars vs 12,631.91 dollars), whereas quality of life (QOL) is superior (0.7247 vs 0.6585 quality-adjusted life years [QALY], rendering LapDN a dominant strategy. The model was robust to all variables, and LapDN remained dominant from a payer perspective. In a worst-case scenario, the ICER for LapDN was at most 2,231.61 dollars per QALY. CONCLUSIONS: LapDN offers improved QOL at lower costs, despite the fact that this analysis included patients treated during the learning curve of LapDN at our institution. By potentially increasing organ donor rates, LapDN may be further cost saving by decreasing the number of patients receiving dialysis.

Health-related quality of life after laparoscopic and open nephrectomy.

BACKGROUND: Postoperative recovery often is assessed with parameters (pain and return to work) susceptible to bias. This study sought objectively to compare postoperative health-related quality of life (HRQL) after laparoscopic and open nephrectomy with the Postoperative Recovery (PRS) (a validated questionnaire designed to assess pain), activities of daily living (ADL), and HRQL in postoperative patients. METHODS: Patients undergoing contemporaneous laparoscopic and open nephrectomy received the PRS pre- and postoperatively. The results were analyzed with analysis of covariance (ANCOV) and survival analysis. RESULTS: The 33 open nephrectomy and 38 laparoscopic patients in this study were comparable in age, gender, body mass index (BMI) and employment. Laparoscopic operative time was longer (p = 0.015), and the hospital stay was shorter (p<0.001). Laparoscopic patients had higher HRQL scores from postoperative days 3 to 365 (p<0.001), and they returned to preoperative HRQL faster (p<0.001). CONCLUSIONS: An objective HRQL instrument confirms that laparoscopic nephrectomy patients recover faster and with a higher HRQL than open surgery patients. The PRS can be modified for use after other abdominal procedures, and may prove useful for comparisons of other minimally invasive surgical techniques.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP).

BACKGROUND: Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP). METHODS: Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients. RESULTS: Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70-335); and median blood loss was 100 cc (range, 20-1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1-12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission. CONCLUSIONS: Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis.

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.