Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection.

BACKGROUND: Laparoscopic colorectal surgery has a long learning curve. Using a modular-based training programme may shorten this. Concerns with laparoscopic surgery have been oncological compromise and poor surgical outcomes when training more junior surgeons. This study aimed to compare operative and oncological outcomes between trainees undergoing a mentored training programme and a consultant trainer. METHODS: A prospective study of all elective laparoscopic colorectal resections was undertaken in a single institution. Operative and oncological outcomes were recorded. All trainees were mentored by a National Laparoscopic Trainer (Lapco), and results between trainer and trainees compared. RESULTS: Three hundred cases were included, with 198 (66%) performed for cancer. The trainer undertook 199 (66%) of operations, whilst trainees performed 101 (34%). Anterior resection was the commonest operation (n = 124, 41%). There were no differences between trainer and trainees for the majority of surgical outcomes, including blood loss (p = 0.598), conversion to open (p = 0.113), anastomotic leak (p = 0.263), readmission (p = 1.000) and death rates (p = 0.549). Only length of stay (p = 0.034), stoma formation (p < 0.01) and operative duration (p = 0.007) were higher in the trainer cohort, reflecting the more complex cases undertaken. Overall, there were no significant differences in both short- and longer-term oncology outcomes according to the grade of operating surgeon, including lymph nodes in specimen, circumferential resection margin and 1- and 2-year radiological recurrence. CONCLUSION: When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.

The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway.

INTRODUCTION: Laparoscopic surgery is well established in the modern management of colorectal disease. More recently, enhanced recovery after surgery (ERAS) protocols have been introduced to further promote accelerated discharge and faster recovery. However, not all patients are suitable for early discharge. The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge. METHODS: Data were prospectively collected on consecutive patients undergoing laparoscopic colorectal surgery. All patients followed the institution's ERAS protocol and were discharged once specific criteria were fulfilled. Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery. Thereafter, the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model. RESULTS: Three hundred patients were included in the analysis. The most common operation was laparoscopic anterior resection (n = 123, 41%). Mean length of stay was 4.8 days (standard deviation 5.9), with 185 (62%) patients discharged within 72 h. Ten (3%) patients had a post-operative complication. Three independent predictors of delayed discharge were identified; BMI (OR 1.06, 95%CI 1.01-1.11), operation length (OR 0.99, 95%CI 0.98-0.99) and complications (OR 16.26, 95%CI 4.88-54.08). CONCLUSIONS: A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay. This enables more than 60% of patients to be discharged within 72 h. Increased BMI, duration of operation and complications post-operatively independently predict a longer length of stay.

Obese patients have similar short-term outcomes to non-obese in laparoscopic colorectal surgery.

AIM: To determine whether obese patients undergoing laparoscopic surgery within an enhanced recovery program had worse short-term outcomes. METHODS: A prospective study of consecutive patients undergoing laparoscopic colorectal resection was carried out between 2008 and 2011 in a single institution. Patients were divided in groups based on body mass index (BMI). Short-term outcomes including operative data, length of stay, complications and readmission rates were recorded and compared between the groups. Continuous data were analysed using t-test or one-way Analysis of Variance. χ(2) test was used to compare categorical data. RESULTS: Two hundred and fifty four patients were included over the study period. The majority of individuals (41.7%) recruited were of a healthy weight (BMI < 25), whilst 50 patients were classified as obese (19.6%). Patients were matched in terms of the presence of co-morbidities and previous abdominal surgery. Obese patients were found to have a statistically significant difference in The American Society of Anesthesiologists grade. Length of surgery and intra-operative blood loss were no different according to BMI. CONCLUSION: Obesity (BMI > 25) does not lead to worse short-term outcomes in laparoscopic colorectal surgery and therefore such patients should not be precluded from laparoscopic surgery.

"An unfortunate trip": small bowel perforation in a patient with an undiagnosed inguinal hernia following minor blunt trauma.

Small bowel perforation due to blunt abdominal trauma associated with inguinal hernia is uncommon. An 80-year-old woman presented to the emergency department following a simple fall and had developed a traumatic perforation of the proximal ileum likely secondary to an undiagnosed inguinal hernia. Following this minor blunt trauma she recovered after an emergency laparotomy and bowel resection.