Laparoscopic Colorectal Surgery Research Articles

Indocyanine green fluorescence imaging for lymph node detection and long-term clinical outcomes in colorectal cancer surgery: A systematic review and meta-analysis.

The indocyanine green fluorescence imaging (ICG-FI) technique is increasingly being used in laparoscopic colorectal surgery for lymph node mapping. However, there is no definitive standard regarding whether the application of this technique can significantly increase the detection rate of metastatic lymph nodes and improve long-term prognosis. PubMed, Embase, Web of Science, and Cochrane Library databases were searched to include studies including ICG-FI in laparoscopic colorectal surgery. Data on the detection rate of lymph nodes, metastatic rate of ICG-positive nodes, and long-term clinical outcomes were extracted following inclusion criteria. Eighteen studies with a total of 1552 patients 922 with ICG-guided laparoscopic and 630 without ICG technique were finally included. Clinical stage II/III colorectal tumors were the most commonly studies types. The patients using the ICG-FI technique had more harvested lymph nodes (weighted mean: 23.5 vs. 18.9; WMD=4.6; p<0.00001) during dissection but a lower metastasis rate of ICG-positive nodes (61/218 [28%] vs. 96/333 [28.9%]; OR=1.45; p=0.08). Compared with conventional laparoscopic colorectal surgery, additional ICG-FI technique did not improve the 3year overall survival rate (272/289 [94.1%] vs. 269/289 [93.1%]; OR=1.19; p=0.61), relapse-free survival (246/289 [85.1%] vs. 249/289 [86.2%]; OR=0.92; p=0.72), and local recurrence rate (22/289 [7.6%] vs. 28/289 [9.7%]; OR=0.77; p=0.38). The overall detection rate of sentinel lymph nodes, lymph flow, and metastatic rate of ICG-positive nodes with the help of ICG-FI were 86.8%, 89.9%, and 22.8%, respectively. No patients experienced major adverse events during ICG injection preoperatively or postoperatively. Indocyanine green fluorescence imaging-guided procedure, compared to conventional laparoscopic dissection, can assist in obtaining a greater number of harvested lymph nodes and metastatic lymph nodes, however, it did not significantly improve the long-term clinical outcomes. Level III systematic review of randomized control and nonrandomized studies.

Domains of four-step technique training program for laparoscopic colorectal surgery.

Many surgeons have begun learning about colorectal surgery using laparoscopy rather than laparotomy. The domains of four-step technique training program (DOF) for laparoscopic colorectal surgery have been designed and implemented by our institute since 2011, and they are expected to provide a safe and effective program for trainees with limited experience in laparoscopic colorectal surgery. The DOF were established with standard surgical procedures, a four-step technique, and learning passports using point credits after the procedure was completed. Patients who underwent minimally invasive colorectal resection at the Chang Gung Memorial Hospital between January 2013 and April 2019 were enrolled. Overall, 2604 and 478 patients were enrolled in the non-training and training groups, respectively. Multivariable logistic regression analysis revealed that the postoperative short-term outcomes were not significantly associated with the training or non-training groups. However, the training group had a significantly longer operative time than the non-training group in the linear regression model. Once the trainee passed the proficiency point (passed 100 points or 30 cases), no significant difference in postoperative short-term outcomes was found between the patients in the non-training and training groups that underwent the entire surgery performed by the trainee. When patients' safety was evaluated in the training cases under the DOF, no higher rates of postoperative morbidity and mortality were found compared to those in cases performed by experienced surgeons. Additionally, trainees who passed the proficiency point during DOF could safely perform the entire laparoscopic colorectal surgery under supervision without further adverse effects on the patients.

ArtiSentialⓇ versus conventional laparoscopic colorectal cancer surgery: a multicenter retrospective matched cohort study

Background: This study aims to compare outcomes of colorectal cancer surgeries performed using the newly developed articulating laparoscopic instrument, ArtiSential®, with those using conventional non-articulating or rigid laparoscopic instruments. Methods: This multicenter, retrospective, matched cohort study enrolled patients with colorectal cancer undergoing laparoscopic surgery in seven tertiary referral hospitals from January 2021 to October 2022. A 1:1 propensity score matching was performed between the articulating (Arti-LAP) and conventional (Rigid-LAP) laparoscopic groups. The primary outcome was the overall incidence of short-term complications. Results: The study initially comprised 694 and 2008 patients in the Arti-LAP and Rigid-LAP groups, respectively. After matching, each group consisted of 694 patients, with no significant differences in baseline clinical characteristics. Mean operation time was 161 ± 32 min in Arti-LAP and 152 ± 25 min in Rigid-LAP groups (P=0.105). Open conversion rates were 0% (0/694) in Arti-LAP and 1.0% (7/694) in Rigid-LAP groups (P=0.024). Overall morbidity rates were 9.5% (66/694) in Arti-LAP and 12.8% (89/694) in Rigid-LAP (P=0.061), with similar rates of severe morbidities. Specimen quality was acceptable in both groups. Multivariable regression analysis showed that the choice of instrument type (articulating or rigid) was not associated with perioperative morbidity. Despite a short median follow-up period of 19.5 months, no significant difference in disease-free survival was observed between the groups. Conclusion: Laparoscopic surgery using ArtiSential® was performed safely and effectively for patients with colorectal cancer. Articulating laparoscopic instruments may offer an advantage in reducing open conversion rates.

Dermatomal spread in lateral quadratus lumborum blocks versus transversus abdominus plane blocks after laparoscopic colorectal surgery: a randomized clinical trial

IntroductionPostoperative pain after laparoscopic abdominal surgery remains complex. While lateral quadratus lumborum (QL) block and transversus abdominus plane (TAP) block are similar techniques, no studies have examined if one technique...

Five-item Modified Frailty Index in Elderly Patients Undergoing Laparoscopic Colorectal Surgery Predicts Postoperative Complications.

Owing to underlying diseases and decreased physiological functions, frailty in elderly patients may be associated with adverse postoperative complications and mortality. To date, there are various frailty assessment methods, with the five-item modified frailty index (mFI-5) being an objective and concise evaluation tool. This study aimed to clarify whether mFI-5 scoring, a measure of frailty, can predict postoperative outcomes in elderly patients undergoing laparoscopic colorectal surgery. A total of 107 patients aged over 80 years who underwent laparoscopic colorectal surgery at Nagasaki University Hospital between 2011 and 2018 were included in this study. The mFI-5 was used to assess the preoperative condition of each patient, with scores compared against various postoperative outcome measures. Univariate analysis was used to determine between-group differences for pre- and post-operative variables. Of the 107 patients [median age, 83 (80-99) years], 44.9% were male. The mFI-5 score was calculated and patients were divided into three groups: 0 (n=36, 33.6%); 1 (n=44, 41.1%); and 2+ (n=27, 25.3%). The groups were significantly associated with the American Society of Anesthesiology (ASA) classification (p<0.001). Postoperative complications occurred in 43 patients (40.2%), and a higher mFI-5 score was significantly associated with postoperative complications of Clavien-Dindo grade ≥III and duration of hospital stay. The mFI-5 is an objective and useful tool for predicting postoperative complications of laparoscopic surgery in elderly patients with colorectal cancer.

Individualized positive end-expiratory pressure in laparoscopic surgery: a randomized controlled trial.

The reduction in functional residual capacity (FRC) is a significant pathological factor in the development of postoperative pulmonary complications. Appropriate positive end-expiratory pressure (PEEP) is critical to preserve FRC during mechanical ventilation. Our previous study suggests that using driving pressure-guided PEEP can reduce postoperative pulmonary complications. In this study, we hypothesize that individualized PEEP can increase immediate postoperative FRC and improve lung ventilation. This single-centered, randomized controlled trial included a total of 91 patients scheduled for laparoscopic surgery for colorectal carcinoma. Patients were randomly assigned to receive individualized PEEP guided by minimum driving pressure or a fixed PEEP of six cmH<inf>2</inf>O. The primary outcome was postoperative FRC. Secondary outcomes included the incidence of postoperative pulmonary complications, postoperative Oxygenation Index, alveolar-arterial oxygen tension difference (P<inf>A-a</inf>O<inf>2</inf>), intrapulmonary shunt (Q<inf>S</inf>/Q<inf>T</inf>), and Respiratory Index, as well as lung ventilation measured by electrical impedance tomography. The median value of PEEP in the individualized group was 14 cmH<inf>2</inf>O, with an interquartile range of 12-14 cmH<inf>2</inf>O. The postoperative FRC was significantly higher in the individualized PEEP group than that in the PEEP six cmH<inf>2</inf>O group (32.8 [12.8] vs. 25.0 [12.6] mL/kg, P=0.004). Patients receiving driving pressure-guided PEEP also had significantly higher Oxygenation Index, better ventilation distribution, and lower PA-aO<inf>2</inf>, Q<inf>S</inf>/Q<inf>T</inf>, and Respiratory Index. Driving pressure-guided PEEP can preserve postoperative FRC and provide better ventilation and oxygenation for patients undergoing laparoscopic colorectal surgery.

Comparison of surgical performance using articulated (ArtiSential®) and conventional instruments for colorectal laparoscopic surgery: A single-centre, open, before-and-after, prospective study.

Rigid surgical instruments limit movement whereas articulated instruments offer better control in small spaces and allow for intuitive and ergonomic movements. However, the effectiveness of the use of articulated instruments in improving colorectal laparoscopic outcomes remains unclear. The aim of this work was to determine whether colorectal laparoscopic surgical proficiency improved when multijoint instruments were used instead of conventional ones. We enrolled 70 consecutive patients (n = 20 for conventional instruments) aged 19-80 years who underwent elective laparoscopic surgery for colorectal diseases. Unedited surgery videos were validated using the modified Global Operative Assessment of Laparoscopic Skills (mGOALS) scale. Learning curves were analysed using a cumulative sum control chart for mGOALS grades. The surgery type, length of hospital stay and 30-day postoperative complication rates were comparable between the groups, and the surgeon's mGOALS grades were similar (p = 0.190). However, in the articulated group, the scores were significantly higher for depth perception (p = 0.012) and tissue-handling domains (p = 0.046), while surgical duration was significantly shorter and intraoperative blood loss was significantly lower (p = 0.022), compared with those in the conventional (p = 0.002) group. Learning curve findings indicated that the first 10 and subsequent 40 surgeries in the articulated group were within the inexperienced and experienced phases, respectively. The mGOALS score in the experienced phase improved in the articulated group compared with that in the conventional group (p = 0.036). The use of articulated instruments in laparoscopic colorectal surgery showed potential benefits. Further studies are needed to confirm these findings.

The efficacy of preemptive multimodal analgesia in elderly patients undergoing laparoscopic colorectal surgery: a randomized controlled trial

Objective To evaluate the effectiveness of preemptive multimodal analgesiain elderly patients undergoing laparoscopic colorectal surgery. Methods A prospective randomized controlled study was conducted in the Department of Gastrointestinal Surgery of the Second Hospital of Hebei Medical University from January 2022 to December 2022. A total of 133 patients were included according to the criteria and randomly divided into preemptive analgesia (PRA) group (test group, 67patients) and postoperative analgesia (POA) group (control group, 66patients). Results The Visual Analog Scale (VAS)scores of PRA group 24 h, 48 h, and 72 h after operation were lower than those of POA group, and the difference was statistically significant, P < 0.001.The incidences of postoperative gastrointestinal dysfunction (POGD) and postoperative delirium (POD)in PRA group were 13.43% and 8.98%, respectively, which were significantly lower than those in POA group (31.82% and 24.24%), P < 0.05. The levels of IL-6 and IL-10 in PRA group after the operation were 17.54 ± 2.13 ng/L and 15.57 ± 1.71 ng/L respectively, which were lower than those in POA group (25.45 ± 2.95 ng/L and 23.45 ± 1.88 ng/L), P < 0.05. The level of acetylcholinesterase(AchE) was 56.34 ± 5.62 nmol/L in the POA group, which was significantly higher than that in the POA group (49.59 ± 5.52 nmol/L), P < 0.001. Conclusion Preemptive multimodal analgesia can reduce the incidence of POGD and POD in elderly patients undergoing laparoscopic gastrocolic surgery, improve the recovery process of postoperative gastrointestinal function, increase the concentrations of propionic acid and butyric acid in short chain fatty acids (SCFAs) and the number of beneficial intestinal bacteria.

Comparative analysis of the safety and effectiveness of robotic natural orifice specimen extraction versus laparoscopic surgery for colorectal tumors through systematic review and meta-analysis.

The purpose of this study and meta-analysis was to evaluate the perioperative and oncologic results of robotic NOSE versus laparoscopic surgery for colorectal tumors. We plan to perform an extensive electronic search on PubMed, CNKI, Embase, and the Cochrane Library to find research articles published from the beginning of the databases until July 2024 that examine the comparison between robotic natural orifice specimen extraction and laparoscopic surgery in patients with colorectal cancer. Both English and Chinese literature will be included. Literature screening will strictly follow predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will be conducted with the Newcastle-Ottawa Scale (NOS). Review Manager 5.4.1 will be utilized to perform a meta-analysis of data gathered from the studies that are included. The ultimate evaluation included seven past cohort studies with a total of 1117 participants (545 who had robotic NOSE and 572 who had laparoscopic surgery). Patients who had robotic NOSE experienced notable enhancements in LOHS, time to first flatus, time to start the liquid diet, EBL, and postoperative ileus when compared to patients undergoing laparoscopic colorectal surgery. There were no notable discrepancies noted in terms of surgical duration, total complications, lymph node collection, and anastomotic leakage between the two methods. In conclusion, the use of robotic technology for extracting specimens through natural body openings in colorectal surgery is considered to be safe and achievable. It offers notable advantages over laparoscopic surgery, including reduced hospital stay, earlier time to first flatus and liquid intake, decreased EBL, and lower incidence of postoperative ileus.

Intraoperative 'pressure field' haemodynamic monitoring in a patient with severe aortic regurgitation having laparoscopic robot-assisted colorectal surgery.

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, leading to myocardial ischaemia and heart failure. Transoesophageal echocardiography (TOE) assists haemodynamic management intraoperatively but requires subspecialist skills and enables limited inferences to be drawn regarding the impact of afterload on myocardial performance. Minimally invasive haemodynamic monitoring enabling real-time visualisation of a patient's 'pressure field' has been suggested as a potential adjunct or alternative to TOE, with the added advantage of providing continuous quantitative information about both stroke volume and the afterload to ventricular ejection in a single visualisation. We describe an example of successful concurrent use of pressure field haemodynamic monitoring and TOE in a patient with severe aortic regurgitation having a prolonged laparoscopic robot-assisted pelvic exenteration.

Is laparoscopic colorectal surgery safe and feasible among elderly patients?

Is laparoscopic colorectal surgery safe and feasible among elderly patients?

The Use of Remote Presence Robotic Tele-Presentation in Rural and Remote Canada: A Systematic Review.

Objective: One potential solution to limited health care in rural and remote regions is remote presence robotic tele-presentation to allow health care providers to care for patients in their home community via a robotic interface. We synthesized evidence regarding the use of remote presence robotic tele-presentation in rural and/or remote Canadian health settings. Methods: Medline, PubMed, and Embase were searched up to August 2023. Remote presence robotic tele-presentation refers to any robotic device used for the purpose of presenting and/or collecting patient information. Primary research was included if the patient was located in remote and/or rural Canada, featured remote presence robotic tele-presentation, and assessed patient, family, or clinician satisfaction, patient transport to nearby regional or urban center, health care costs, clinical outcomes, infrastructure outcomes, adverse events, or telementoring. Results: Six studies were included. Patients, nurses, and physicians all reported high levels of satisfaction when using the remote presence robotic tele-presentation. Fifty to sixty-three percent of patients were managed in their home community and did not require transfer to another center. Remote presence robotic sonography resulted in adequate imaging in 81% of first trimester ultrasound limited exams but was less useful for second trimester complete obstetric ultrasounds (20% adequate imaging). Two of eight laparoscopic colorectal surgeries had to be converted to open surgeries. Telerobotic ultrasound clinics resulted in a diagnosis in 70% of cases. Conclusions: Evidence suggests remote presence robotic tele-presentation is a safe and cost-effective approach to providing care in distant communities and can prevent some transfers and evacuations to tertiary hospitals.

Perioperative Use of Intravenous Lidocaine Infusion to Decrease Postoperative Opioids in Colorectal Surgery: A Randomized Prospective Study

Pain is defined as an unpleasant sensory and emotional sensation provoked by real tissue damage and manifested by autonomic, psychological, and behavioral reactions. Improvement of postoperative pain control remains a significant challenge among clinicians. 40 patients aged 30-60 years, ASA 1-2 scheduled for colorectal surgery, were divided into two groups 20 patients each. Lidocaine group: (n= 20) received bolus intravenous lidocaine 20 min before incision with a dose of 1.5mg/kg followed by lidocaine infusion with a dose of 1.5mg/kg/h. Control group: (n= 20) receive intravenous lidocaine only. After premedication with a bolus dose of lidocaine at induction, the heart rate was lower in the interventional group compared with the control one until 12 hours post-operatively, then returned to be equal by 24 hours. Between recovery and one hour postoperative, intraoperative serial differences were significant only for the intervention group. After premedication and during the operation until 24 hours, postoperative mean blood pressure was significantly higher among controls. This returns to be equal by 48 hours and beyond. The postoperative VAS score and analgesic requirements were significantly lower in the lidocaine infusion group. Perioperative lidocaine infusion provides analgesia, low pain score, and decreases postoperative opioid consumption in laparoscopic colorectal surgery.

Evaluation and analysis of neurocognitive dysfunction in patients with colorectal cancer after radical resection: A retrospective study.

With the continuous progress of colorectal cancer treatment technology, the survival rate of patients has improved significantly, but the problem of postoperative neurocognitive dysfunction has gradually attracted attention. To analyze the risk factors for delayed postoperative neurocognitive recovery (DNR) after laparoscopic colorectal cancer surgery and constructed a risk prediction model to provide an evidence-based reference for the prevention and treatment of DNR after laparoscopic colorectal cancer surgery. The clinical data of 227 patients with colorectal cancer who underwent laparoscopic surgery and regional cerebral saturation oxygenation (rScO2) monitoring at our hospital from March 2020 to July 2022 were retrospectively analyzed. Common factors and potential factors affecting postoperative DNR were used as analysis variables, and univariate analysis and multifactor analysis were carried out step by step to determine the predictors of the model and construct a risk prediction model. The predictive performance of the model was assessed by the receiver operating characteristic (ROC) curve, the calibration curve was used to assess the fit of the model to the data, and a nomogram was drawn. In addition, 30 patients who met the inclusion and exclusion criteria from January 2023 to July 2023 were selected for external verification of the prediction model. The incidence of postoperative DNR in the modeling group was 15.4% (35/227). Multivariate analysis revealed that age, years of education, diabetes status, and the lowest rScO2 value were the independent influencing factors of postoperative DNR (all P < 0.05). Accordingly, a DNR risk prediction model was constructed after laparoscopic colorectal cancer surgery. The area under the ROC curve of the model was 0.757 (95%CI: 0.676-0.839, P < 0.001), and the Hosmer-Lemeshow test of the calibration curve suggested that the model was well fitted (P = 0.516). The C-index for external validation of the row was 0.617. The DNR risk prediction model associated with rScO2 monitoring can be used for individualized assessment of patients undergoing laparoscopic colorectal cancer surgery and provides a clinical basis for the prevention of DNR after surgery.

WP1.14 - Evaluation of mesh closure of laparotomy and extraction incisions in open and laparoscopic colorectal surgery: A systematic review and meta-analysis

Abstract Background In colorectal surgery, postoperative evisceration and incisional hernia (IH) were not only noted after open procedures, but also at extraction incision (EI) sites used in laparoscopic resections. Few techniques, including using different sutures, closure techniques, and surgical meshes, have been evaluated in the literature to prevent the occurrence of IH and postoperative wound failure. This systematic review investigates the efficacy and safety of using prophylactic mesh on closure of midline laparotomy or extraction incision (EI) in colorectal oncological and non-oncological resections. Method Literature databases, including PubMed, Cochrane, Science Direct and Google Scholar, were searched for studies comparing the use of prophylactic mesh to conventional suture closure in colorectal operations, either in laparotomy closure in open surgery or EI closure in laparoscopic procedures, regardless of the indication; oncological and non-oncological. Primary endpoints were identified as incisional hernia (IH), and postoperative evisceration. Other outcomes included surgical site infection (SSI), seroma formation and length of hospital stay (LOS). Results Six studies fulfilled the inclusion criteria and studied 1,398 patients. Occurrence of IH was significantly reduced on using mesh closure compared to suture closure (OR 0.23, P=0.00001), while there was no statistically significant difference in evisceration rate (OR 0.51, P=0.25). Additionally, no notable difference was identified between both groups in terms of SSI (OR 1.20, P=0.54), postoperative seroma (OR 1.80, P=0.13), and LOS (MD -0.54, P=0.63). Conclusion The use of prophylactic mesh on closing laparotomy incision or EI for open and laparoscopic colorectal resections reduces the risk of developing IH. There were no significant safety concerns; however, further randomised trials may provide more creditable results.

Low pneumoperitoneum pressure on venous thromboembolism in laparoscopic colorectal cancer surgery: A randomized controlled study

IntroductionVenous thromboembolism (VTE) poses a significant risk in colorectal cancer surgeries due to hypercoagulability and the anatomical challenges of the pelvic cavity. With the advancement of minimally invasive techniques, intraoperative strategies for preventing VTE may prove to be effective. This study explores the effects of intraoperative pneumoperitoneum pressures on VTE incidence following colorectal cancer surgeries. MethodsThis single center parallel randomized controlled double-blind, trial involved 302 patients undergoing elective laparoscopic or robotic colorectal surgery. Patients were randomized to either a standard pneumoperitoneum pressure group (SP: 15 mmHg) or a low-pressure group (LP: 10 mmHg). Primary outcomes measured were the incidence of VTE, including symptomatic and asymptomatic DVT and PE. Secondary outcomes included postoperative D-dimer levels, surgery duration, blood loss, surgeon satisfaction, and oncological quality. ResultsOut of 302 randomized patients, 275 were evaluable post exclusions, with 138 in the SP group and 137 in the LP group. The incidence of VTE was 10.9 % in the SP and 13.9 % in the LP group, with no significant difference between the two (P = 0.450). Secondary outcomes such as D-dimer levels, surgery duration, and blood loss showed no significant differences between two groups. Surgeon satisfaction and oncological outcomes were similarly comparable. ConclusionsThe trial demonstrated no significant difference in the incidence of VTE between standard and low pneumoperitoneum pressures. This suggests that lower pressures may not necessarily provide a benefit in reducing postoperative VTE in colorectal cancer surgeries.

Lower extremity pain and/or numbness after laparoscopic surgery and robot-assisted surgery in the lithotomy position combined with the Trendelenburg position.

The purpose of this study was to investigate the incidence and risk factors of lower extremity pain and/or numbness after laparoscopic colorectal surgery and robot-assisted laparoscopic radical prostatectomy in the lithotomy position combined with the Trendelenburg position. The relationship between creatine kinase (CK) levels and lower extremity pain and/or numbness was also investigated. We retrospectively reviewed adult patients who underwent laparoscopic colorectal surgery and robot-assisted laparoscopic radical prostatectomy in the lithotomy position combined with the Trendelenburg position between May 2015 and April 2020. Logistic regression analysis was used to identify risk factors of lower extremity pain and/or numbness. Preoperative and postoperative CK levels were compared in patients with and those without lower extremity pain and/or numbness. Among 940 patients, 1.9% experienced lower extremity pain and/or numbness postoperatively. The incidences of lower extremity pain and/or numbness after laparoscopic colorectal surgery and after robot-assisted laparoscopic radical prostatectomy were 1.7% and 2.1%, respectively. Multivariate logistic regression analysis revealed that only duration of surgery > 4h (odds ratio = 3.144, 95% CI: 1.102-8.969, p = 0.032) was a significant predictor of lower extremity pain and/or numbness. Postoperative median CK level in patients with lower extremity pain and/or numbness was significantly higher than that in patients without lower extremity pain and/or numbness. The incidence of lower extremity pain and/or numbness after laparoscopic colorectal surgery was comparable to that after robot-assisted laparoscopic radical prostatectomy. Prolonged duration of surgery contributed to lower extremity pain and/or numbness. Significantly elevated CK levels in patients with lower extremity pain and/or numbness suggest the involvement of muscle injury in these symptoms.

Remote monitoring after elective colorectal surgery, a pilot study

BackgroundMultiple studies have demonstrated safety of short stay after colorectal resections. Remote patient monitoring may allow earlier discharge home after surgery. Remote patient monitoring feasibility after elective colorectal surgery in a largely rural state was evaluated. MethodsA pilot study was undertaken May-August 2023 for patients >18 years of age, fluent in English, with compensated medical morbidities who underwent elective minimally invasive colorectal surgery. Patients were monitored at home with pulse oximetry, heart rate, blood pressure, and weight for 2 weeks. A remote nurse assessed and escalated to the colorectal surgery department as needed. Patients answered daily surveys on pain, ostomy/incision, bowel function, and oral intake. Patient satisfaction was surveyed on days 5 and 12 using a 5-point Likert scale. ResultsSixteen patients undergoing laparoscopic colorectal surgery were enrolled preoperatively. The average length of stay was 3.0 days (1–9), 43% for malignancy, and 25% for inflammatory bowel disease. In 25% of cases, conversion to open surgery was required. The average home monitoring system set-up time was 53 minutes. Two patients were noncompliant. A third patient had a late loss of digital services. The remote nurse detected 2 complications: port site infection and delayed ileus. One required readmission. Patient satisfaction scores were high for the entire study period. Operation by third party failed in all attempted cases. ConclusionRemote home monitoring is a safe, feasible, and well-liked option for patients undergoing minimally invasive colorectal surgery in rural areas. Complex disease, compensated morbidities, and conversion to open surgery were not contraindications to early discharge.

Assessing risk factors for elevated creatine kinase levels as an indicator of compartment syndrome following laparoscopic or robot-assisted colorectal cancer surgery in the lithotomy-trendelenburg position

BackgroundWell-leg compartment syndrome (WLCS) can occur due to compression and lower limb circulation disturbances caused by the surgical position during the procedure. Although rare, with an incidence of 1 in 3500 surgeries performed in the lithotomy position, it can lead to serious complications. Therefore, prevention and early diagnosis are critical. Symptoms of WLCS, such as leg pain, swelling, paresthesia, and serum creatine kinase (CK) levels are useful for diagnosis. This study aimed to investigate the risk factors for postoperative CK elevation in laparoscopic or robot-assisted colorectal cancer surgery performed in the lithotomy-Trendelenburg position.MethodsPostoperative CK levels were measured in 178 patients who underwent laparoscopic or robot-assisted colorectal cancer surgery between February 2022 and March 2023. We compared patient backgrounds, short-term outcomes, and thigh/calf circumferences between patients with CK levels ≥ 250 (n = 62) and those with CK levels < 250 (n = 116). We investigated risk factors for elevated CK levels using both univariate and multivariate analyses.ResultsFour patients with CK levels of 22405 U/L, 4685 U/L, 4050 U/L, and 3824 U/L reported symptoms, which improved with conservative treatment. The following independent prognostic factors were identified by multivariate analysis: male sex (odds ratio [OR], 4.403; 95% CI, 1.960 to 9.892), rectal surgery (OR, 2.779; 95% CI, 1.249 to 6.184), continuous head-down position duration ≥ 180 min (OR, 3.523; 95% CI, 1.552 to 7.997), and preoperative calf circumference ≥ 33 cm (OR, 2.482; 95% CI, 1.154 to 5.339).ConclusionsRisk factors for CK elevation after colorectal cancer surgery in the lithotomy position include male sex, rectal surgery, an extended continuous head-down position without position changes, and a larger preoperative calf circumference. This study highlights the potential importance of intraoperative position changes every 3 h for preventing elevated CK levels, although the preventive effect was not specifically examined.

Effects of neuromuscular block reversal with neostigmine/glycopyrrolate versus sugammadex on bowel motility recovery after laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveTo compare the effects of neostigmine/glycopyrrolate (a traditional agent) and sugammadex on bowel motility recovery and the occurrence of digestive system complications after colorectal surgery. DesignProspective, randomized controlled trial. SettingA single tertiary center. Patients111 patients undergoing laparoscopic colorectal surgery. InterventionsPatients were randomized into two groups based on the block reversal agent: 1) a mixture of 50 μg.kg−1 of neostigmine and 10 μg.kg-1 of glycopyrrolate (neostigmine group) and 2) 2 mg.kg−1 of sugammadex (sugammadex group). MeasurementsThe primary outcome was the time from the surgery's completion to the first flatus.The time to the first postoperative defecation, incidences of postoperative nausea or vomiting, ileus, and dry mouth, as well as postoperative length of stay, were also assessed. Main resultsThe time to the first flatus was significantly shorter in the sugammadex group than in the neostigmine group (59 [42–79] h vs 69 [53–90] h, P = 0.027). The time to the first defecation and the incidences of postoperative nausea or vomiting and ileus did not differ between the groups, nor did the postoperative length of stay. However, the incidence of postoperative dry mouth was significantly lower in the sugammadex group than in the neostigmine group (7 patients [13%] vs 39 patients [71%], P < 0.001). ConclusionsThe time to the first flatus was shorter using 2 mg.kg−1 sugammadex to reverse the neuromuscular block for laparoscopic colorectal surgery compared to reversal with conventional neostigmine/glycopyrrolate.