Hand-assisted laparoscopic colectomy: the learning curve is for operative speed, not for quality.

AIM: We aimed to define the learning curve for hand-assisted laparoscopic colectomy (HALC). METHOD: A retrospective analysis of prospectively recorded data was performed. Consecutive segmental and total HALC performed by a single surgeon with no prior HALC experience was included. Operative time and quality-related outcomes, including conversions, operative and postoperative complications, length of stay, reoperations and readmissions were compared for consecutive cohorts of 25 HALC. A subgroup analysis of right, left, total and proctocolectomy performed in each cohort of 25 HALC was also performed. RESULTS: From December 2005 to February 2009, 200 HALC were performed. When evaluated in cohorts of 25 consecutive cases, operative times (155-206 min), operative complications (4-12%), postoperative complications (8-36%), length of stay (4-5 days), reoperations (0-8%) and readmissions (0-16%) were similar. In the subgroup analysis, there were no changes in the quality-related measures for any colectomy type or the operative time for right and proctocolectomy as experience was gained. Operative time decreased for left (183-127 min) and total HALC (259-218 min) after experience with 50 cases (P < 0.05). CONCLUSION: HALC operative times decreased with surgeon experience. For quality-related outcomes, there was no learning curve for HALC.

Clinical outcomes of ileorectal anastomosis for ulcerative colitis.

BACKGROUND: The aim of this study was to determine the fate of the rectum, functional results and quality of life after ileorectal anastomosis (IRA) in ulcerative colitis. METHODS: Patients with ulcerative colitis and indeterminate colitis who underwent IRA from 1971 to 2006 were evaluated retrospectively. Twenty-two patients with an IRA were matched by age, sex and follow-up duration with 66 patients with an ileal pouch-anal anastomosis (IPAA) and compared for functional outcomes and quality of life. RESULTS: Eighty-six patients with an IRA were included. Median follow-up was 9 (range 1-36) years. Rectal dysplasia and cancer rates were 17 and 8 per cent respectively. The rectum was resected in 46 patients (53 per cent) because of refractory proctitis in 24, rectal dysplasia in 15 and rectal cancer in seven. The cumulative probability of having a functioning IRA at 10 and 20 years was 74 and 46 per cent respectively. Patients with an IRA had fewer bowel movements (P = 0.020) and less night-time seepage (P = 0.020) but increased urgency (P < 0.001) compared with patients with an IPAA, whereas quality of life was similar. CONCLUSION: In selected patients with ulcerative colitis IRA gives an acceptable quality of life and functional outcome that are comparable to those in patients with an IPAA. Owing to the risk of cancer, surveillance of the rectum is mandatory.

Infliximab in ulcerative colitis is associated with an increased risk of postoperative complications after restorative proctocolectomy.

PURPOSE: Little data exist regarding infliximab use in surgical decision making and postoperative complications in ulcerative colitis. Our goals were to determine the rate of postoperative complications in infliximab-treated ulcerative colitis patients undergoing restorative proctocolectomy and to determine whether three-stage procedures are more often necessary. METHODS: We studied a group of infliximab-treated patients and matched control subjects who underwent two-stage restorative proctocolectomy between 2000 and 2006. Postoperative complications were compared. In addition, the rate of three-stage procedures was compared between all infliximab- and noninfliximab-treated patients. RESULTS: A total of 523 restorative proctocolectomies were performed. In the infliximab group, there were 46 two-stage and 39 three-stage procedures. Covariate-adjusted odds of early complication for the infliximab group was 3.54 times that of controls (P = 0.004; 95 percent confidence interval (CI), 1.51-8.31). The odds of sepsis were 13.8 times greater (P = 0.011; 95 percent CI, 1.82-105) and the odds of late complication were 2.19 times greater (P = 0.08; 95 percent CI, 0.91-5.28) for infliximab. The odds of requirement for three-stage procedures was 2.07 times greater in the infliximab group (P = 0.011; 95 percent CI, 1.18-3.63). CONCLUSIONS: Infliximab increases the risk of postoperative complications after restorative proctocolectomy and has altered the surgical approach to ulcerative colitis. Potential benefits of infliximab should be balanced against these risks.

Fever evaluations after colorectal surgery: identification of risk factors that increase yield and decrease cost.

PURPOSE: This study was designed to evaluate the yield and cost of fever evaluations in average-risk inpatients after elective colorectal surgery. METHODS: A 12-month, retrospective study was performed on patients who developed a postoperative fever > or = 38 degrees C after elective colorectal surgery. A positive fever evaluation was defined as a blood culture, urine culture, chest x-ray, or abdominal CT result that led to a change in patient management. Logistic regression, Fisher's exact test, and chi-squared test were used; odds ratios were calculated. RESULTS: Of 133 patients, 26 percent had a positive evaluation. Blood culture, urine culture, chest x-ray, and CT were positive in 3, 8, 7, and 46 percent, respectively. Risk factors for a positive fever evaluation were temperature > or = 38.5 degrees C, fever evaluation after postoperative Day 6, and a clinical manifestation of systemic inflammatory response syndrome other than fever (all, P < 0.01). The cost per positive fever evaluation for the entire group, patients with 2 risk factors, or patients with 3 risk factors was $5,600, $4,200, and $2,140, respectively. CONCLUSIONS: The current approach to fever evaluation after elective colorectal surgery is low yield and costly. High fever, late postoperative fever, and systemic inflammatory response syndrome are risk factors for a positive fever evaluation after colorectal surgery.

[TIPS - Transjugular intrahepatic portosystemic shunt. A review]. / TIPS - anastomose portossistêmica intra-hepática transjugular. Revisão.

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.