Open Colorectal Surgery Research Articles

Learning curve of enhanced recovery after surgery program in open colorectal surgery.

BACKGROUNDEnhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients’ outcomes is unknown.AIMTo evaluate and establish a learning curve of ERAS program for open colorectal surgery.METHODSThis was a review of prospectively collected database of 380 “unselected” patients undergoing elective “open” colectomy and/or proctectomy under ERAS protocol from 2011 (commencing ERAS application) to 2017 in a university hospital. Patients were divided into 5 chronological groups (76 cases per quintile). Surgical outcomes and ERAS compliance among quintiles were compared. Learning curves were calculated based on criteria of optimal recovery: defined as absence of major postoperative complications, discharge by postoperative day 5, and no 30-d readmission.RESULTSHospitalization more than 5 d occurred in 22.6% (n = 86), major complication was present in 2.9% (n = 11) and 30-d readmission rate was 2.4% (n = 9) accounting for unsuccessful recovery of 25% (n = 95). Conversely, the overall rate of optimal recovery was 75%. The optimal recovery significantly increased from 57.9% in 1st quintile to 72.4%-85.5% in the following quintiles (P < 0.001). Average compliance with ERAS protocol gradually increased over the time - from 68.6% in 1st quintile to 75.5% in 5th quintile (P < 0.001). The application of preoperative counseling, nutrition support, goal-directed fluid therapy, O-ring wound protector and scheduled mobilization significantly increased over the study period.CONCLUSIONA number of 76 colorectal operations are required for a multidisciplinary team to achieve a significantly higher rate of optimal recovery and high compliance with ERAS program for open colorectal surgery.

Analysis of patients with colorectal cancer treated with surgery in 2015 and 2016, using a statistical model

The purpose of this study was to analyze the data of the open and laparoscopic colorectal cancer surgeries countrywide in an administrative database of the National Health Insurance Fund of Hungary in 2015-2016. Hungarian surgical data of colorectal cancer from 2015-2016 were analyzed based on the following objectives: diagnosis of care, complications and co-morbidities; age; sex and medical institutions. We used crosstabs and partial least squares path modeling to analyze the relations between data groups. Results of three LVPLS models (group of open, laparoscopic interventions and the whole population of the survey) were compared. From the 4941 analyzed operative cases, 4562 were open and 379 laparoscopic. Based on the three LVPLS models, we found nexus between complication groups and co-morbidity groups and progressivity of medical institutions in laparoscopic operations. As far as complications, in the laparoscopic model bleeding and anaemia, in cases of total population and open operations septic complications played dominant role. Laparoscopic resections in patients with multiple co-morbidities are carried out in medical institutions with high professional progressivity most frequently. In cases of laparoscopic colorectal operations, the higher the progressivity of an institution, the lower the complication rate was. Differences in the results in the models may be due to patient selection, and further research should be carried out in this regard. Anaemia and bleeding are dominant complication factors in the laparoscopic model, which are influenced by patient selection besides the differenced in surgical technique. Orv Hetil. 2019; 160(11): 426-434.

Lack of online video educational resources for open colorectal surgery training

Video recordings of open surgical procedures could provide a method for enhancing surgical education, analysing operative performance and presenting cases to a wider audience of surgeons. The aim of this pilot study was to systematically search the World Wide Web to determine the availability of open surgery videos and to evaluate their potential training value in terms of the educational content presented. A broad search for open right hemicolectomy videos was performed on the three most used English language internet search engines (Google.com, Bing.com and Yahoo.com). All videos of open right hemicolectomy with an English language title were included. Laparoscopic surgery, single-incision laparoscopic surgery and robotic- and hand-assisted surgery videos were excluded, as were videos from fee charging websites. A total of 31 relevant websites were identified and 21 open surgery videos were finally included. The characteristics of the patients were presented only in four (19%) videos. A video commentary was present in 12 cases (57.1%) and this was in English language in 11. The median number of views per month was 84.1. Open surgery videos have a significantly higher number of views per month compared to laparoscopic surgery videos, but current methodologies used to record and render the surgeon's point of view in open operative surgery remain limited.

Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease.

Background and Objectives:The role for the robotic-assisted approach as a minimally invasive alternative to open colorectal surgery is in the evaluation phase. While the benefits of minimally invasive colorectal surgery when compared to the open approach have been clearly demonstrated, the adoption of laparoscopy has been limited. The purpose of this study was to evaluate clinical outcomes, hospital and payer characteristics of patients undergoing robotic-assisted, laparoscopic, and open elective sigmoidectomy for diverticular disease in the United States.Methods:This is a retrospective propensity score–matched analysis. The Premier Healthcare Database was queried for patients with diverticular disease. Patients with diverticular disease who underwent robotic-assisted, laparoscopic, and open sigmoidectomy for diverticular disease from January 2013 through September 2015 were included. Propensity-score matching (1:1) facilitated comparison of robotic-assisted versus open approach and robotic-assisted versus laparoscopic approach. Peri-operative outcomes were assessed for both comparisons.Results:There were several outcomes advantages for the robotic-assisted approach when compared to laparoscopic and open sigmoidectomy for diverticular disease that included significantly fewer conversions to open (P = .0002), shorter hospital length of stay, fewer postoperative complications—ileus, wound complications, and acute renal failure—and more patients discharged directly to home.Conclusions:The robotic-assisted minimally invasive approach to elective sigmoidectomy for diverticular disease results in favorable intra-operative and postoperative outcomes when compared to laparoscopic and open approaches.

The effect of the introduced infection control measures on surgical site infection for open colorectal surgery

The effect of the introduced infection control measures on surgical site infection for open colorectal surgery

Short-term surgical outcomes of laparoscopic colorectal cancer resection in Assiut University Hospital

BackgroundLaparoscopic surgery has progressively replaced open colorectal surgery in recent decades owing to better short-term outcomes. The current study was designed to detect the short-term surgical outcomes of laparoscopic colorectal cancer resection.Patients and methodsA prospective study was conducted including 30 patients diagnosed with surgically treatable colorectal cancer in Department of General Surgery, Assiut University Hospital.ResultsA total of 30 patients underwent laparoscopic colonic or rectal resections between January 2017 and January 2018. They were followed up for 1 year. There were significantly improved short-term surgical outcomes in the form of less blood loss, earlier return of bowel function, and decreased hospital stay. Histological examination revealed that proximal and distal margins were free of tumor cells in all surgical specimens.ConclusionLaparoscopic colorectal cancer resection provides many clinical benefits in the form of small incision, shorter hospital stay, faster recovery, and faster return of intestinal function. In addition, it shows no significant increase of intraoperative and/or postoperative complications, and with similar oncological radicality, morbidity and mortality rates, compared with open surgery.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery.

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery. A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis. Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of >3.5kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with >3.5l at POD 0 and two (3%) in the group with <3.5l at POD 0 (P=0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge. A weight gain of >3.5kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Structured training program in colorectal surgery: the robotic surgeon as a new paradigm.

One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.

Quadratus Lumborum Block Versus Perioperative Intravenous Lidocaine for Postoperative Pain Control in Patients Undergoing Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-blind Controlled Clinical Trial.

To investigate the comparative analgesic efficacy of systemic lidocaine and quadratus lumborum (QL) block in laparoscopic colorectal surgery. Although epidural analgesia is the standard to control pain in patients undergoing open colorectal surgery, optimal analgesic management in laparoscopic surgery is less well-defined. There is need for effective and efficient alternatives to epidural analgesia for pain management in patients undergoing laparoscopic colorectal surgery. A total of 125 patients undergoing laparoscopic colorectal surgery were included in this randomized, double-blind controlled clinical trial. Patients randomly received an intravenous infusion with placebo plus a QL-block with placebo, a QL-block with ropivacaine 0.25% plus intravenous placebo, or intravenous lidocaine plus a QL-block with placebo. Postoperatively, all patients received patient-controlled intravenous anesthesia (PCIA) with morphine. Primary outcome parameter was the opioid consumption during the first 24 hours postoperatively. Secondary endpoints included severity of postoperative pain, time to return of intestinal function, incidence of postoperative nausea and vomiting, and length of hospital stay. The QL-block was not superior to systemic lidocaine for the reduction of morphine requirements in the first 24 hours postoperatively {QL-group: 37.5 (28.4) mg [mean (standard deviation)] vs lidocaine group: 40.2 (25) mg, P = 0.15}. For the majority of secondary outcome parameters, no significant differences were found between the groups. Morphine consumption in the postanesthesia care unit, the number of PCIA-boli demanded by the patient, and the number of PCIA-boli delivered by the PCIA-pump during the first 24 hours postoperatively were lower in the placebo group. In our trial, the QL-block did not provide superior postoperative analgesia when compared to systemic lidocaine in laparoscopic colorectal surgery. Eudra CT: 2014-001499-73; 31/7/2014.

Use of Prophylactic Mesh When Creating a Colostomy Does Not Prevent Parastomal Hernia: A Randomized Controlled Trial-STOMAMESH.

Objective:The aim of this study was to determine whether parastomal hernia (PSH) rate can be reduced by using synthetic mesh in the sublay position when constructing permanent end colostomy. The secondary aim was to investigate possible side-effects of the mesh.Background:Prevention of PSH is important as it often causes discomfort and leakage from stoma dressing. Different methods of prevention have been tried, including several mesh techniques. The incidence of PSH is high; up to 78%.Methods:Randomized controlled double-blinded multicenter trial. Patients undergoing open colorectal surgery, including creation of a permanent end colostomy, were randomized into 2 groups, with and without mesh. A lightweight polypropylene mesh was placed around the colostomy in the sublay position. Follow up after 1 month and 1 year. Computerized tomography and clinical examination were used to detect PSH at the 1-year follow up. Data were analyzed on an intention-to-treat basis.Results:After 1 year, 211 of 232 patients underwent clinical examination and 198 radiologic assessments. Operation time was 36 minutes longer in the mesh arm. No difference in rate of PSH was revealed in the analyses of clinical (P = 0.866) and radiologic (P = 0.748) data. There was no significant difference in perioperative complications.Conclusions:The use of reinforcing mesh does not alter the rate of PSH. No difference in complication rate was seen between the 2 arms. Based on these results, the prophylactic use of mesh to prevent PSH cannot be recommended.

Opioid-free colorectal surgery: a method to improve patient & financial outcomes in surgery.

Opioids are a mainstay for postsurgical pain management, but have associated complications and costs, and contribute to the opioid epidemic. While efforts to reduce opioid use exist, little study has been done on opioid utilization and its impact across surgical approaches. Our goal was to evaluate the impact of opioid utilization on quality measures and costs after open and laparoscopic colorectal surgery. The Premier database was reviewed for inpatient colorectal procedures from January 01, 2014, to September 30, 2015. Procedures were stratified into open and laparoscopic approaches, then "opioid" and "opioid-free" groups within each approach. Univariate analysis compared demographics, outcomes, and cost by opioid use and surgical approach. In the "opioid" groups, opioid consumption and duration were assessed across platforms. Multivariate regression analyzed the association between opioid use and surgical approach on costs and quality outcomes. 50,098 procedures were evaluated-40.4% laparoscopic and 59.6% open. 6.6% of laparoscopic and 5.3% of open cases were "opioid free." Across both approaches, patients over 65 were most likely opioid free, while the obese and cancer patients were most likely to use opioids. Length of stay was shorter, and post-discharge nursing needs and total costs were lower in the "opioid-free" group in both approaches (all p < 0.001). The median daily and total opioid consumption were lower with a laparoscopic approach (p < 0.001), which also had a shorter duration of use versus open cases (p < 0.001). Opioids were 20% more likely in open cases. Total costs were 16% greater with opioids and 24% greater in open surgery. Complications were 89% more likely in open surgery. Readmissions were increased by 14% with both opioid use and open surgery. Opioid-free colorectal surgery results in improved outcomes, and laparoscopy further improves these results. Continued efforts to increase laparoscopy are key for reducing opioids and improving outcomes as we transition to value-based care.

Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial

Objective Determine if negative pressure wound therapy (NPWT) reduces surgical site infection (SSI) in primarily closed incision after open and laparoscopic-converted colorectal surgery. Background SSIs after colorectal surgery are a common cause of morbidity. The prophylactic effect of NPWT has not been established. We undertook this study to evaluate if, among patients undergoing open colorectal resection, NPWT, as compared with standard postoperative dressings, is associated with a reduction in the rate of postoperative SSI. Methods In a randomized, controlled trial, 300 patients undergoing elective open colorectal surgery were assigned to receive prophylactic NPWT or standard gauze dressing. The primary end-point was 30-day SSI, as assessed by wound care experts blinded to treatment arm. Secondary outcomes included length of stay. Statistical analysis was performed on an intention-to-treat basis. A priori subgroup analysis was planned for patients who received a stoma at the time of initial operation. Results The incidence of SSI at 30-days postoperatively was no different between experimental and control groups (32% vs 34% respectively, P = 0.68). Length of stay was also no different at a median of 7 days (IQR 5) for both groups. Among patients receiving a stoma, there was also no difference in SSI between the experimental and control groups (38% vs 33% respectively, P = 0.66). Conclusions Prophylactic use of NPWT on primarily closed incisions after open colorectal surgery was not associated with a decrease in SSI rate when compared with standard gauze dressing. Trial registration number Clinicaltrials.gov (NCT02007018).

The role of mechanical bowel preparation and oral antibiotics for left-sided laparoscopic and open elective restorative colorectal surgery with and without faecal diversion

There is significant variation in the use of mechanical bowel preparation and oral antibiotics prior to left-sided elective colorectal surgery. There has been no consensus internationally. This was a retrospective analysis of the 2015 American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into four groups: those who had mechanical bowel preparation with oral antibiotics, mechanical bowel preparation alone, oral antibiotics alone and no preparation. The main outcome measures included overall, superficial, deep and organ/space surgical site infections. Secondary outcomes included anastomotic leak, ileus and rate of Clostridium difficile. A total of 5729 patients were included for analysis. The overall surgical site infection rate (any superficial, deep or organ/space infection) was significantly lower in the mechanical bowel preparation and oral antibiotics approach when compared to no preparation (OR = 0.46, 95% CI 0.36-0.59, P < 0.0001). On multivariable logistic regression analysis, mechanical bowel preparation with oral antibiotics maintained a lower risk of overall surgical site infections. MBP and OAB also had a protective effect on anastomotic leak in both the laparoscopic and open cohorts (laparoscopic multivariable adjusted OR = 0.42 (0.19-0.94), P = 0.035; open multivariable adjusted OR = 0.3 (0.12-0.77), P = 0.012). Mechanical bowel preparation alone and oral antibiotics alone was not associated with a significant decrease in surgical site infections. There was no increase in C. difficile occurrences with the use of oral antibiotics. Mechanical bowel preparation with oral antibiotics significantly minimised surgical site infections and anastomotic leak following both laparoscopic and open left-sided restorative colorectal surgery. Mechanical bowel preparation alone did not reduce surgical site infections. There was a trend to reduction in surgical site infections with oral antibiotics alone.

Prophylactic closed-incision negative-pressure wound therapy is associated with decreased surgical site infection in high-risk colorectal surgery laparotomy wounds.

AimSurgical site infection in colorectal surgery is associated with significant healthcare costs, which may be reduced by using a closed‐incision negative‐pressure therapy device. The aim of this study was to assess the impact of closed‐incision negative‐pressure therapy on the incidence of surgical site infection.MethodIn this retrospective cohort study we evaluated all patients who had undergone high‐risk open colorectal surgery at a single tertiary care centre from 2012 to 2016. We compared the incidence of surgical site infection between those receiving standard postoperative wound care between 2012 and 2014 and those receiving closed‐incision negative‐pressure therapy via a customizable device (Prevena Incision Management System, KCI, an Acelity company, San Antonio, Texas, USA) between 2014 and 2016. A validated surgical site infection risk score was used to create a 1:1 matched cohort subset.ResultsNegative pressure therapy was used in 77 patients and compared with 238 controls. Negative pressure patients were more likely to have a stoma (92% vs 48%, P < 0.01) and to be smokers (33% vs 15%, P < 0.01). Surgical site infection was higher in control patients (15%, n = 35/238) compared with negative pressure patients (7%, n = 5/77) (P = 0.05). On regression analysis, negative pressure therapy was associated with decreased surgical site infection (OR 0.27; 95% CI 0.09–0.78). These differences persisted in the matched analysis.ConclusionNegative pressure therapy was associated with decreased surgical site infection. Negative pressure therapy offers significant potential for quality improvement.

Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study

Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.

Stress biomarkers in minimally invasive and conventional colorectal resections

Introduction: Any surgical procedure develops a stress situation for the patient, which can modulate the individual outcome. At present, there is only limited information about stress response in colorectal resections by laparoscopic compared to conventional surgery. Therefore, our objectives were the feasibility and the investigation of stress biomarkers including copeptin and steroid hormones before, during and after colorectal surgery.Methods: Eleven patients underwent minimally invasive and ten patients conventionally open colorectal surgery. Blood samples were collected before, during and 24 h after surgery and copeptin, NT-proBNP, cortisol, cortisone, interleukin-6 and glucose were analyzed.Results: Both, minimally invasive and conventional-open colorectal surgery caused a fast but heterogeneous response of stress biomarkers. However, the postoperative decrease of cortisol, cortisone and glucose differed between both groups. The stress biomarkers decreased faster down to baseline after minimally invasive surgery, while in open surgery cortisol, cortisone and glucose did not return to baseline within 24 h after operation.Conclusions: We show in this feasibility study for the first time an increase of copeptin in combination with glucocorticoids as stress biomarkers by open surgery compared to minimally invasive procedures in patients undergoing colorectal surgery. Exceeding an individual threshold of ‘stress burden’ may have unfavorable effects on the long-time clinical outcome.

The perioperative dynamics of IL-7 following robot-assisted and open colorectal surgery

Interleukin-7 is critical for T-cell development and displays antimicrobial and antitumor properties. It is referred to as a “critical enhancer of protective immunity”. However, there is no information on interleukin-7 dynamics following colorectal surgery. Moreover, although robot-assisted surgery is gaining popularity, data on the immune response to it is almost non-existent. In this prospective non-randomized case-control study we found interleukin-7 dynamics to differ following robot-assisted and open approach and to affect postoperative immunity. Linear increases were seen in the robotic group while a cubic pattern with a maximum at 8 h in the open one. Low preoperative interleukin-7 was associated with developing surgical site infection. In turn, higher preoperative interleukin-7 was associated with preserved immune function: less pronounced drop in lymphocyte count and higher Δlymphocyte/Δneutrophil ratio in patients undergoing robotic surgery. The changes in other cytokines, namely, interleukin-12(p70), TNFα, interferon-γ, and interleukin-10 were independently associated with interleukin-7 dynamics. In turn, relative changes in interleukin-7 were independent predictors of changes in interferon-γ, key cytokine of favourable Th1 immune response. Taken together, we demonstrated different perioperative dynamics of interleukin-7, which may contribute to favourable outcomes following robotic colorectal surgery including lower incidence of surgical site infections, milder surgery-induced lymphopenia, and beneficial interferon-γ dynamics.

Mosapride reduces the incidence of prolonged postoperative ileus after open colorectal surgery

Mosapride reduces the incidence of prolonged postoperative ileus after open colorectal surgery

Conventional Epidural vs Transversus Abdominis Plane Block with Liposomal Bupivacaine: A Randomized Trial in Colorectal Surgery

Colorectal surgery is a focus of enhanced recovery protocols (ERP). The use of transversus abdominis plane (TAP) block for abdominal surgery has demonstrated effectiveness in ERP, however, no direct comparison of epidural vs TAP for nonanalgesic clinical factors has been published to date. The primary aim of this study was to compare epidural with TAP for length of stay in colorectal surgery. Patients undergoing open and laparoscopic colorectal surgery were prospectively randomized into epidural (n= 39) or TAP (n= 44) groups preoperatively. Anesthesiologists performed blocks in the preoperative area. A standardized ERP and discharge protocol were initiated on patients. Five patients unable to complete the ERP due to unrelated postoperative complications or technical factors were excluded from analysis. The study arms were statistically similar for demographic factors, operations, and intraoperative measures. Time to first flatus was equivalent in both groups (postoperative day 1.7 vs 1.9; p= 0.39). Length of stay was shorter with TAP (postoperative day 3.3 vs 2.8; p=0.023). Postoperative nausea and vomiting rates were higher with TAP (14% vs 33%; p= 0.057). Urinary retention occurred with higher frequency with epidural (30% vs 15%; p= 0.11). Transversus abdominis plane block was associated with a 0.5-day reduction in length of stay in a standardized ERP compared with epidural. Early indication favors TAP in patients with a history of postoperative urinary retention, as a trend of urinary retention was associated with epidural. Transversus abdominis plane block offers an effective alternative to epidural in colorectal surgery, regardless of operative approach.

Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012

AimLaparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown.MethodsAdults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002–2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined.ResultsLaparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20–0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12–0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002–2003 to 2011–2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9–15.2%).ConclusionsThere was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.