Open Low Anterior Resection Research Articles

Robot‐assisted radical cystectomy for bladder cancer after low anterior resection: A case report

AbstractRadical cystectomy after low anterior resection is rare, and no cases of robotic surgery have been reported. Cystectomy in patients who have undergone a previous pelvic surgery, whether open or endoscopic, requires caution to avoid damaging other organs due to anatomical changes caused by adhesions in a limited space. Additionally, the curative nature of the treatment must be maintained. We describe a 69‐year‐old man with a history of open low anterior resection for rectal cancer who underwent robot‐assisted radical cystectomy with extracorporeal ileal conduit construction. Although this procedure is challenging, it was performed safely with the collaboration of colorectal surgeons. The patient was discharged without perioperative complications and remained recurrence‐free for 5 years.

Have outcomes following colectomy in the United States improved over time?

BackgroundThere has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale. MethodsAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses. Results261,301 patients, 135,876 (52 ​%) female, with a median age of 62 (IQR 53–72) were included. Across all years, MIS partial colectomy was the most common procedure (37 ​%), followed by MIS low anterior resection (27 ​%), open partial colectomy (24 ​%), and open low anterior resection (12 ​%). MIS increased from 59 ​% in 2012–2014 to 66 ​% in 2018–2020 (p ​< ​0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4–7) in 2012–2014 to 4 days (IQR 3–6) in 2018–2020 (p ​< ​0.001). Superficial surgical site infections decreased from 5.5 ​% in 2012–2014 to 2.9 ​% in 2018–2020 (p ​< ​0.001). Deep surgical site infections similarly decreased from 1.1 ​% to 0.4 ​% between these periods (p ​< ​0.001). Pulmonary embolism also decreased from 0.6 ​% to 0.5 ​% between periods (p ​= ​0.02). 30-day mortality was unchanged at 1.7 ​% between 2012-2014 and 2018–2020 (p ​= ​0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 ​% decrease in postoperative length of stay (p ​< ​0.001). ConclusionsBetween 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally.

Neoadjuvant Chemoradiation for Rectal Cancer Achieves Satisfactory Tumour Regression and Local Recurrence – Result of a Dedicated Multi-disciplinary Approach from a South Asian Centre

BackgroundPre-operative long-course chemoradiotherapy (CRT) for rectal cancer has resulted in improvement in rates of restorative rectal resection and local recurrence by inducing tumour downstaging and downsizing. Total mesorectal excision (TME) is a standardised surgical technique of low anterior resection aimed at the prevention of local tumour recurrence. The purpose of this study was to evaluate tumour response following CRT in a standardised group of patients with rectal cancer.MethodsOne hundred and thirty-one patients (79 male; 52 female, median age 57; interquartile range 47–62 years) of 153 with rectal cancer who underwent pre-operative long-course CRT were treated by standardised open low anterior resection at a median of 10 weeks post-CRT. Sixteen of 131 (12%) were 70 years or older. Median follow-up at the time of analysis was 15 months (interquartile range 6–45 months). Pathology reports were analysed based on AJCC-UICC classification using the TNM system. Data recorded were overall/subgrades of tumour regression; good, moderate or poor, lymph node harvest, local recurrence, disease-free and overall survival using standard statistical methods.Results78% showed tumour regression post-CRT; 43% displayed good tumour regression/response while 22% had poor tumour regression/response. All patients had a pre-operative T-stage of either T3 or T4. Post-operation, good responders had a median T stage of T2 vs. T3 in poor responders (P = 0.0002). Overall, the median lymph node harvest was < 12. There was no difference in the number of nodes harvested in good vs. poor responders (Good/moderate-6 nodes vs. Poor- 8; P = 0.31). Good responders tended to have a lesser number of malignant nodes vs. poor responders (P = 0.31). Overall, local recurrence was 6.8% and the anal sphincter preservation rate was 89%. Predicted 5-year disease-free and overall survival were similar between good and poor responders.ConclusionLong-course CRT resulted in satisfactory tumour regression and enabled consideration for safe, sphincter-saving resection in rectal cancer. A dedicated multi-disciplinary team approach achieved a global benchmark for local recurrence in a resource-limited setting.

Lower need for allogeneic blood transfusion after robotic low anterior resection compared with open low anterior resection: a propensity score-matched analysis

Robotic low anterior resection (R-LAR) for rectal cancer may decrease estimated blood loss compared with open low anterior resection (O-LAR). The aim of this study was to compare estimated blood loss and blood transfusion within 30 days after O-LAR and R-LAR. This was a retrospective matched cohort study based on prospectively registered data from Västmanland Hospital, Sweden. The first 52 patients operated on using R-LAR for rectal cancer at Västmanland Hospital were propensity score-matched 1:2 with patients who underwent O-LAR for age, sex, ASA (American Society of Anesthesiology physical classification system), and tumor distance from the anal verge. In total, 52 patients in the R-LAR group and 104 patients in the O-LAR group were included. Estimated blood loss was significantly higher in the O-LAR group compared with R-LAR: 582.7 ml (SD ± 489.2) vs. 86.1 ml (SD ± 67.7); p < 0.001. Within 30 days after surgery, 43.3% of patients who received O-LAR and 11.5% who received R-LAR were treated with blood transfusion (p < 0.001). As a secondary post hoc finding, multivariable analysis identified O-LAR and lower pre-operative hemoglobin level as risk factors for the need of blood transfusion within 30 days after surgery. Patients who underwent R-LAR had significantly lower estimated blood loss and a need for peri- and post-operative blood transfusion compared with O-LAR. Open surgery was shown to be associated with an increased need for blood transfusion within 30 days after low anterior resection for rectal cancer.

The Effects of Hospital Volume on Short-Term Outcomes of Laparoscopic Surgery for Rectal Cancer: A Large-Scale Analysis of 37,821 Cases on a Nationwide Administrative Database

Introduction: Laparoscopic low anterior resection (L-LAR) has become widely accepted for the treatment of rectal cancer. However, little is known about the superiority of L-LAR in a real-world setting (including low-volume hospitals) and the association between the short-term outcomes and hospital volume focusing on L-LAR. Methods: This is a retrospective cohort study. A total of 37,821 patients who underwent LAR for rectal cancer were analyzed using the Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. The short-term surgical outcomes were analyzed using a multilevel analysis. Hospital volumes were divided into quartiles, including low (1–31), middle (32–55), high (56–91), and very-high volume (92–444 resections per 4 years). The effects of hospital volume on the outcomes were investigated. Results: The study population included 8,335 patients (22%) who underwent open low anterior resection (O-LAR) and 29,486 patients (78%) who underwent L-LAR. The in-hospital mortality and morbidity were consistent with previous reports. In patients who underwent L-LAR, the in-hospital mortality (0.12% vs. 0.41%; OR: 0.33; p = 0.005), the rate of reoperation (3.76% vs. 6.48%; OR: 0.67; p < 0.001), and the perioperative transfusion rate (3.81% vs. 5.90%; OR: 0.66; p < 0.001) were significantly lower in very-high-volume hospitals than in low-volume hospitals. These effects of hospital volume were not observed in O-LAR. Conclusions: Our present study demonstrates that high volume improves outcomes in patients who underwent L-LAR in a real-world setting.

Surgical outcomes of robotic, laparoscopic, and open low anterior resection after preoperative chemoradiotherapy for patients with advanced lower rectal cancer.

We investigated the surgical outcomes of robotic low anterior resection (LAR) for lower rectal cancer after preoperative chemoradiotherapy (pCRT). A total of 175 patients with lower rectal cancer who underwent LAR after pCRT between 2005 and 2020 were stratified into open (OS, n = 65), laparoscopic (LS, n = 64), and robotic surgery (RS, n = 46) groups. We compared the clinical, surgical, and pathological results among the three groups. The RS and LS groups had less blood loss than the OS group (p < 0.0001). The operating time in the RS group was longer than in the LS and OS groups (p < 0.0001). The RS group had a significantly longer mean distal margin than the LS and OS groups (25.4mm vs. 20.7mm and 20.3mm, respectively; p = 0.026). There was no significant difference in the postoperative complication rate among the groups. The local recurrence rate in the RS group was comparable to those in the LS and OS groups. Robotic LAR after pCRT was performed safely for patients with advanced lower rectal cancer. It provided a longer distal margin and equivalent local control rates.

PD30-06 RATES OF NEWLY DIAGNOSED ERECTILE DYSFUNCTION AFTER SURGERY FOR COLORECTAL CANCER

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation II (PD30)1 Sep 2021PD30-06 RATES OF NEWLY DIAGNOSED ERECTILE DYSFUNCTION AFTER SURGERY FOR COLORECTAL CANCER Christopher Gaffney, Nahid Punjani, Aaron Brant, Jonathan Fainberg, Xinyan Zheng, Art Sedrakyan, and James Kashanian Christopher GaffneyChristopher Gaffney More articles by this author , Nahid PunjaniNahid Punjani More articles by this author , Aaron BrantAaron Brant More articles by this author , Jonathan FainbergJonathan Fainberg More articles by this author , Xinyan ZhengXinyan Zheng More articles by this author , Art SedrakyanArt Sedrakyan More articles by this author , and James KashanianJames Kashanian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002031.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Abdominoperineal resection (APR) and low anterior resection (LAR) for colorectal cancer (CRC) are associated with high rates of erectile dysfunction (ED) in case series that may be underdiagnosed in practice. We sought to explore rates of new diagnoses of ED after both minimally invasive (MIS) and open LAR, APR and hemicolectomy. METHODS: The Surveillance, Epidemiology, and End Results–Medicare database was used to record new diagnoses of ED after an index procedure (MIS or open LAR, APR or hemicolectomy) for CRC. The primary outcome was a new diagnosis of ED within 2 years of the index procedure. Men aged >66 years with any index procedure within 1 year of diagnosis of CRC were included. Men with a history of ED, metastatic CRC or prostate or bladder cancer prior to their index procedure were excluded. We performed a Cox proportional hazard model adjusting for baseline demographic factors, procedure group, procedure type (MIS versus open), Charlson comorbidity index, tumor stage and grade, history of chemoradiation therapy, and socioeconomic status through 2 years of follow up. RESULTS: Of 60, 648 men diagnosed with CRC between 2004-2015, 28,387 met inclusion criteria. 21,650 (76.4%) men were treated with hemicolectomy, 4,814 (17.0%) with LAR, and 1,883 (8.7%) with APR. On multivariable analysis, the hazard ratio (HR) for a new diagnosis of ED was 1.28 (95%CI 1.08 to 1.51) for LAR and 1.46 (95%CI 1.12-1.90) for APR compared to hemicolectomy. Other factors associated with a diagnosis of ED were black race (HR 2.01, 95%CI 1.63-2.48), geography (Southern compared to Northeast region) (HR 1.20 95%CI 1.08-1.57), and MIS (HR 1.43, 95%CI 1.25-1.65). Kaplan Meyer analysis detailing the increased rate of ED diagnoses in patients treated with APR and LAR as compared to hemicolectomy is seen in Figure 1. CONCLUSIONS: Compared to hemicolectomy, men treated with LAR and APR and men treated with MIS as compared to open surgery have higher rates of new ED diagnoses within 2 years of treatment. The absolute rate of ED diagnoses was low compared to prior carefully annotated case series, suggesting that patients are frequently underdiagnosed. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e534-e534 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Gaffney More articles by this author Nahid Punjani More articles by this author Aaron Brant More articles by this author Jonathan Fainberg More articles by this author Xinyan Zheng More articles by this author Art Sedrakyan More articles by this author James Kashanian More articles by this author Expand All Advertisement Loading ...

Lateral lymph node recurrence of rectal cancer with a pathological complete response to chemotherapy confirmed by laparoscopic lateral lymph node dissection: A case report

Lateral lymph node (LLN) metastasis is one of the forms of local recurrence after surgery for lower rectal cancer. We here present a case of LLN recurrence of rectal cancer that was shown by laparoscopic lateral lymph node dissection (LLND) to have a complete pathological response to chemotherapy. A 58-year-old man underwent open low anterior resection for lower rectal cancer. After detection of right LLN recurrence 43 months after the operation, 11 cycles of capecitabine, oxaliplatin, and bevacizumab chemotherapy were administered. Laparoscopic right LLND was performed 55 months after the first operation. Pathological examination revealed no viable tumor cells in the dissected lymph nodes. The patient remains alive without recurrence 61 months after the first surgery and 6 months after laparoscopic LLND. Laparoscopic LLND for LLN recurrence of rectal cancer is feasible and should be considered a valid treatment option.

Association of Complications with Healthcare Utilization and Hospital-Borne Costs Among Patients Undergoing Open Low Anterior Resection Using Curved Cutter Staplers.

PurposeThe ability of curved cutter staplers (CCS) to conform to the complex anatomy of the rectum has led to their widespread use in open low anterior resection (LAR). We describe the incidence of complications and their association with healthcare utilization and hospital-borne costs among patients who underwent open LAR with CCS, with the intent to provide contextual epidemiologic and economic burden data for future evaluations of innovations that may lead to a reduced incidence of complications.MethodsRetrospective cohort study using Premier Healthcare Database. Studied patients were ≥18 years who underwent inpatient open LAR with CCS between October 1, 2016 and March 30, 2020 (index admission). Complications of interest included anastomotic leak, bleeding, infection, transfusion, and device complications/adverse incidents during the index admission. Outcomes included index admission hospital length of stay (LOS), non-home discharge status, total operating room (OR) time, total hospital-borne costs, and all-cause readmissions within 30, 60, and 90 days post discharge from index admission. Multivariable regression models were used to compare outcomes between patients with vs without any complication of interest.ResultsThe study included 618 patients with a mean age of 61 years, of whom 57% were males. The incidence proportion of any complication during the index admission for open LAR with CCS was 28% (95% CI: [23.9%, 31.0%], n=170). As compared with patients experiencing no complications, those with a complication had higher adjusted mean total hospital costs ($38,159 vs $22,303, p<0.001), non-home discharge status (21.8% vs 9.2%, p=0.004), mean LOS (13 days vs 6 days, p<0.001), and mean OR time (362 mins vs 291 mins, p<0.001). There were no significant differences in all-cause readmissions between patients with vs without complications.ConclusionAmong patients undergoing open LAR with CCS, over a quarter of patients experienced a complication, resulting in a substantial burden to the healthcare system.

Similarities and differences between study designs in short- and long-term outcomes of laparoscopic versus open low anterior resection for rectal cancer: A systematic review and meta-analysis of randomized, case-matched, and cohort studies.

AimRandomized controlled trials (RCT) are the gold standard in surgical research, and case‐matched studies, such as studies with propensity score matching, are expected to serve as an alternative to RCT. Both study designs have been used to investigate the potential superiority of laparoscopic surgery to open surgery for rectal cancer, but it remains unclear whether there are any differences in the findings obtained using these study designs. We aimed to examine similarities and differences between findings from different study designs regarding laparoscopic surgery for rectal cancer.MethodsSystematic review and meta‐analyses. A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane. RCT, case‐matched studies, and cohort studies comparing laparoscopic low anterior resection and open low anterior resection for rectal cancer were included. In total, 8 short‐term outcomes and 3 long‐term outcomes were assessed. Meta‐analysis was conducted stratified by study design using a random‐effects model.ResultsThirty‐five studies were included in this review. Findings did not differ between RCT and case‐matched studies for most outcomes. However, the estimated treatment effect was largest in cohort studies, intermediate in case‐matched studies, and smallest in RCT for overall postoperative complications and 3‐year local recurrence.ConclusionFindings from case‐matched studies were similar to those from RCT in laparoscopic low anterior resection for rectal cancer. However, findings from case‐matched studies were sometimes intermediate between those of RCT and unadjusted cohort studies, and case‐matched studies and cohort studies have a potential to overestimate the treatment effect compared with RCT.

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis.

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol.

Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.

Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients

This observational study was conducted to compare the rate of symptomatic anastomotic leakage (AL), as defined by precise criteria, between laparoscopic and open surgery in patients with mid-to-low rectal cancer using a relatively novel statistical technique. A total of 1014 consecutive low anterior resection (LAR) patients were registered, of whom 936 were included in this prospective, multicenter, and cohort study (UMIN-CTR, Number 000004017). Patients with rectal cancer within 10cm from the anal verge underwent either open or laparoscopic LAR at one of the 40 institutions in Japan from June 2010 to February 2013. The primary endpoint of this study was to compare the rate of symptomatic AL between the two groups before and after propensity score matching (PSM). The secondary endpoint was to analyze the risk factors for symptomatic AL in open and laparoscopic surgery. After PSM, the incidence of symptomatic AL in open and laparoscopic surgery was 12.4 and 15.3%, respectively (p=0.48). AL requiring relaparotomy occurred after 3.8% of open surgeries and 6.2% of laparoscopic surgeries (p=0.37). Multivariate analysis identified male gender as an independent risk factor for symptomatic AL following laparoscopic surgery (p=0.001; odds ratio 5.2; 95% CI 2.0-13.8), and male gender (p=0.004; odds ratio 2.6; 95% CI 1.3-5.6), tumor size (p=0.002; odds ratio 1.2; 95% CI 0.7-0.9), and number of stapler firing (p=0.04; odds ratio 4.1; 95% CI 1.0-15.0) following open surgery. The rate of symptomatic AL was comparable following laparoscopic and open LAR in this large, multicenter, cohort study after PSM. Male gender was associated with an increased risk of symptomatic AL after laparoscopic LAR.

Retrospective observational study on the incidence of incisional hernias after reversal of a temporary diverting ileostomy following rectal carcinoma resection with follow-up CT scans.

Wounds resulting from the closure of temporary stomas have a high risk of developing an incisional hernia (IH) with incidences around 30% in studies designed to investigate this outcome. A temporary diverting ileostomy (TDI) is often used in patients after low anterior resection (LAR) for rectal cancer. The OSTRICH study is a retrospective cohort study of rectal cancer patients who had a LAR with a reversed TDI and at least one CT scan during follow-up. Two radiologists independently evaluated all abdominal CT scans to diagnose IH at the ileostomy wound and additionally, IH at the laparotomy site. From the oncological database of rectal cancer patients treated from 2003 till 2012 (n = 317) a cohort of 153 patients that fulfilled the inclusion criteria was identified. Rectal cancer resection was performed by laparoscopy in 53 patients (34.6%) and by laparotomy in 100 patients (65.4%). A total of 17 IH (11.1%) was diagnosed at the former stoma site after a mean follow-up of 2.6 years. Of these, 8 IH were in patients who had a laparoscopic LAR (15.1%) and 9 IH in patients who had an open LAR (9.0%) (Fisher's exact test; p = 0.28). IH on the other abdominal wall incisions was reported in 69 patients (45.1%). Of these, 10 patients underwent laparoscopic rectal surgery (18.9%) and in 59 patients had open rectal surgery (59.0%) (Fisher's exact test; p < 0.0001). We found a lower number of incisional hernias (11.1%) after reversal of ileostomies than expected from the literature. In contrast to the findings at the ileostomy site, a very high frequency of IH (59.0%) after LAR by laparotomy was found, which was significantly higher than after laparoscopic LAR.

Laparoscopic Versus Open Low Anterior Resection for Rectal Cancer: Results from the National Cancer Data Base

BackgroundWhile the use of laparoscopy has increased among patients undergoing colorectal surgery, there is ongoing debate regarding the oncologic equivalence of laparoscopy compared to open low anterior resection (LAR) for rectal cancer. MethodsThe 2010–2011 NCDB was queried for patients undergoing LAR for rectal cancer. Subjects were grouped by laparoscopic (LLAR) versus open (OLAR) technique. Baseline characteristics were compared. Subjects were propensity matched, and outcomes were compared between groups. ResultsA total of 18,765 patients were identified (34.3 % LLAR, 65.7 % OLAR). After propensity matching, all baseline variables were highly similar except for carcinoembryonic antigen (CEA) level. Complete resection was more common in patients undergoing LLAR (91.6 vs. 88.9 %, p < 0.001), and statistically significant benefits were observed for gross, microscopic, and circumferential (>1 mm) margins (all p < 0.001). There was no difference in median number of lymph nodes obtained (15 vs. 15). Patients undergoing LLAR had shorter lengths of stay (5 vs. 6 days, p < 0.001) without a corresponding increase in 30-day readmission rates (6 vs. 7 %, p = 0.02). ConclusionsLaparoscopic LAR appears to result in equivalent short-term oncologic outcomes compared to the traditional open approach as measured via surrogate endpoints in the NCDB. While these results support the increasing use of laparoscopy in rectal surgery, further data are necessary to assess long-term outcomes.

Understanding Surgical Residents’ Postoperative Practices and Barriers and Enablers to the Implementation of an Enhanced Recovery After Surgery (ERAS) Guideline

An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge. The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis. Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge. Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required.

975 Short-Term Oncologic Outcomes Are Superior Following Laparoscopic Versus Open Low Anterior Resection for Rectal Cancer: Results From the National Cancer Database

975 Short-Term Oncologic Outcomes Are Superior Following Laparoscopic Versus Open Low Anterior Resection for Rectal Cancer: Results From the National Cancer Database

Comparing incidence of enterocolitis after laparoscopic and open low anterior resection for stage II/III rectal cancer

We recently observed an increased incidence of severe enterocolitis following laparoscopic low anterior resection (LAR) in some patients with stage II/III rectal cancer. This study aimed to examine the influence of laparoscopic LAR on postoperative enterocolitis compared with open LAR for Stage II/III rectal cancer. From April 2002 to March 2012, we evaluated 65 patients with stage II/III cancer of the upper or lower rectum who underwent LAR. Among these, 27 patients underwent open LAR and 38 underwent laparoscopic LAR. First, we compared short-term outcomes between the two groups. Next, we evaluated the incidence of postoperative enterocolitis in the laparoscopic LAR group. The clinicopathological factors were examined by univariate and odds ratio (OR) analysis. Univariate analysis revealed significant differences in the occupancy rate, tumor location, depth of tumor invasion, operative time, amount of intraoperative blood loss, and postoperative enterocolitis between the laparoscopic and open groups. Postoperative enterocolitis developed in 6 of 38 patients (15.8%) in the laparoscopic group and in no patient in the open group. The occurrence of postoperative enterocolitis was significantly associated with BMI (≥28 kg/m(2) ), operative time, and wound infection in the laparoscopic LAR group (OR: 0.11, 95% confidence interval: 0.044-0.280, P < 0.05; OR: 1.40, 95% confidence interval: 1.068-1.835, P < 0.05; and OR: 15.0, 95% confidence interval, 1.752-128.310, P < 0.05, respectively). Postoperative enterocolitis occurred more frequently after laparoscopic LAR than after open LAR in patients with stage II/III rectal cancer. Clinical management in the perioperative period of laparoscopic LAR is necessary to prevent postoperative enterocolitis in obese patients and those with a prolonged operative time.

A preliminary study of transcaecal ileostomy as an alternative to defunctioning ostomies

To evaluate the usefulness of a transcaecal ileostomy catheter for protecting distal lower rectal anastomosis as an alternative to conventional ileostomy. Patients with a rectal cancer located 3-10cm from the anal verge were included in the study. In all cases, an open low or ultra-low anterior resection of the rectum was performed with total mesorectal excision. A balloon catheter was inserted through the caecum and ileocaecal valve, with the catheter's distal end placed in terminal ileum. A computed tomography (CT) scan was performed 7days postoperatively to check the integrity of the anastomosis; the transcaecal catheter was withdrawn if no complications were detected. Eighteen patients were treated with a transcaecal catheter. Two patients developed cellulitis (11.1%) in the catheter exit wound. In both cases, successful healing was achieved within a month of surgery. One patient had anastomotic dehiscence (5.5%) after removal of the catheter following a normal CT examination. The median hospital stay was 10days (range 8-13days). A transcaecal ileostomy catheter to protect a distal rectal anastomosis is a potential alternative to loop ileostomy with potentially fewer complications and without need for a second procedure for closure.