Prospective Case-matched Study Research Articles

C-reactive protein monitoring after ileocecal resection and stoma closure reduces length of hospital stay: a prospective case-matched study in 410 patients with Crohn's disease.

The aim of this study was to evaluate a C-reactive protein (CRP)-driven monitoring discharge strategy for patients with Crohn's disease (CD) undergoing laparoscopic ileo-cecal resection (ICR) and if needed, temporary stoma closure (SC). Four hundred and ten patients who underwent laparoscopic ICR for CD: 153 patients (CRP group) between June 2016 and June 2020 at our department, had a CRP-driven monitoring discharge on postoperative day (POD) 3 and were discharged on POD 4 if CRP < 100mg/L. These patients were matched (according to age, sex, body mass index, type of CD (and stoma or not) to 257 patients who underwent laparoscopic ICR for CD between January 2009 and May 2016, without CRP monitoring (Control group). For SC, 79 patients with CRP monitoring were matched with 88 control patients. Primary outcome was overall length of hospital stay (LHS). Secondary outcomes were discharge on POD 4 for SC and POD 4 and POD 6 for ICR, 3-month postoperative overall morbidity and severe morbidity rates, surgical site infection, readmission rates, and CRP level in cases of morbidity at 3months. For ICR without stoma, mean LHS was significantly shorter in the CRP group than in the control group (6.9 ± 2days vs 8.3 ± 6days, p = 0.017). Discharge occurred on POD 6 (or before) in 73% of the patients (CRP group) vs 60% (Control group) (p = 0.027). For ICR with stoma, LHS was 8days for both groups (p = 0.612). For SC, LHS was significantly shorter in the CRP group than in the control group (5.5 ± 3days vs 7.1 ± 4days; p = 0.002). Discharge occurred on POD 4 in 62% (CRP group) vs 30% (Control) (p = 0.003). Postoperative 3-month overall and severe morbidity, and rehospitalization rates were similar between groups. CRP-driven monitoring discharge strategy after laparoscopic ICR for CD is associated with a significant reduction of LHS, without increasing morbidity, reoperation or rehospitalisation rates.

Morbidities After Cardiac Surgery: Impact on Children’s Quality of Life and Parents’ Mental Health

BackgroundMost children now survive cardiac surgery, and the focus of quality improvement initiatives has shifted toward more complex outcome measures. The aim of this investigation was to study the impact of early postoperative morbidities on parent-reported patient quality of life and parental anxiety or depression over 6 months.MethodsThis prospective case-matched cohort study was conducted in 5 UK children’s cardiac centers. Measures of impact for patient categories of “single morbidity,” “multiple morbidities,” and “extracorporeal life support (ECLS)” were compared with “no morbidity.” The measures used were the Pediatric Quality of Life Inventory (PedsQL) and the 4-item Patient Health Questionnaire (PHQ-4) at 6 weeks and 6 months postoperatively. The study modeled the outcomes using mixed effects regression, adjusting for case mix and clustering within centers.ResultsThe study included 666 patients who underwent operation at a median age of 81 days (interquartile range, 10 to 325 days). At 6-week follow-up, significant adjusted differences to the reference group with no morbidity were found for total PedsQL scores, which were lower in patients with ECLS (P = .01), multiple morbidities (P < .001), and a single morbidity (P = .04), as well as the proportion of parents with anxiety and depression, which were higher in the group with multiple morbidities (P = .04 and P = .01, respectively). At 6 months, measures had improved in all morbidity groups. The only significant adjusted difference in the reference group was for physical PedsQL scores in ECLS (P = .04) and multiple morbidities (P < .01).ConclusionsPatient and parent well-being are strongly influenced by postoperative morbidities early after surgery, with improvement by 6 months. Family psychological support and holistic rehabilitation are vital for children who experience postoperative morbidities.

Personalised three-dimensional printed transparent kidney model for robot-assisted partial nephrectomy in patients with complex renal tumours (R.E.N.A.L. nephrometry score ≥7): a prospective case-matched study.

To evaluate the effectiveness of a three-dimensional (3D) printed transparent kidney model as a surgical navigator for robot-assisted partial nephrectomy (RPN) in patients with complex renal tumours, defined by a R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score of ≥7. A total of 80 patients who underwent RPN were included in the present prospective case-matched study (case group [n=40, application of 3D-printed transparent kidney model during RPN] vs matching group [n=40, routine protocol]). The RPNs were performed by a single experienced surgeon. The RPN procedure consisted of six steps: (i) preparation of the renal hilar vessel for clamping, (ii) tumour detection and dissection, (iii) robotic ultrasonography, (iv) tumour resection, (v) calyx repair and haemostasis, and (vi) renorrhaphy. The time for each step, console time, and warm ischaemia time were compared between the two groups as a surrogate marker for surgical effectiveness. Both groups were well-balanced for all baseline characteristics. The use of the model reduced the console time by ~20% compared to the matched group (64.6 vs 78.5min, P=0.001). On multivariate logistic regression analysis, tumour radius (P<0.001) and application of the model (P=0.009) were identified as significant predictors of a console time of ≤70min. We established the usefulness of a personalised 3D-printed transparent kidney model for more effective RPNs. Use of the 3D-printed transparent kidney model reduced the operative time even for complex renal tumours and would be expected to broaden the indications for PN.

Intra-operative fluorescence angiography is reproducible and reduces the rate of anastomotic leak after colorectal resection for cancer: a prospective case-matched study.

Intra-operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left-sided colonic or low anterior resection with anastomosis for colorectal cancer. All patients with left-sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA-). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end-point. In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra-operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788-0.998, P<0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA- group compared to the IOFA+ group (16.7% vs 2.4%, P=0.026) involving significantly more anastomotic dehiscence which required re-intervention (19% vs 2.4%, P=0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA- group compared with the IOFA+ group (9.5% vs 0%, P=0.040). In this prospective case-matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible.

Hospital stay for temporary stoma closure is shortened by C-reactive protein monitoring: a prospective case-matched study.

C-reactive protein (CRP) has been suggested as a satisfactory early marker of postoperative complications after colorectal surgery. The aim of this study was to assess the impact of a CRP monitoring-driven discharge strategy, after stoma reversal following laparoscopic sphincter-saving surgery for rectal cancer. Eighty-eight patients who had stoma reversal between June 2016 and April 2018 had CRP serum level monitoring on postoperative day (POD) 3 and, if necessary, on POD5. Patients were discharged on POD4 if the CRP level was < 100 mg/L. Patients were matched [according to age, gender, body mass index, neoadjuvant pelvic irradiation, type of anastomosis (stapled or manual), and adjuvant chemotherapy] to 109 identical control patients who had stoma reversal between 2012 and 2016 with the same postoperative care but without CRP monitoring. Postoperative 30-day overall morbidity [CRP group: 12/88 (14%) vs controls: 11/109, (10%), p = 0.441] and severe morbidity rates (i.e. Dindo 3-4) [CRP group: 2/88 (2%) vs controls: 2/109 (2%), p = 0.838] were similar between groups. Mean length of stay was significantly shorter in the CRP group (CRP group: 4.6 ± 1.3 vs controls: 5.8 ± 1.8 days; p < 0.001). Discharge occurred before POD5 in 59/88 (67%) CRP patients vs 15/109 (14%) controls (p < 0.001). The unplanned rehospitalization rate [CRP group: 6/88 (7%) vs controls: 4/109 (4%), p = 0.347] was similar between groups. In patients having temporary stoma closure after laparoscopic surgery for rectal cancer, postoperative CRP monitoring is associated with a significant shortening of hospital stay without increasing morbidity or rehospitalization rates.

Association of Marijuana Use With Psychosocial and Quality of Life Outcomes Among Patients With Head and Neck Cancer

Cannabis sativa, the most widely used illicit substance in Canada, has a unique ability to facilitate relaxation and relieve anxiety while reducing pain. However, no study to date has examined quality of life (QOL) and psychosocial issues in relation to the use of this drug among patients with newly diagnosed head and neck cancer (HNC). To examine the differences in QOL and psychosocial outcomes between marijuana users and nonusers with newly diagnosed HNC. This prospective cohort study was conducted at a tertiary care cancer center. Patients were enrolled consecutively and prospectively at the time of HNC diagnosis from January 1, 2011, to January 1, 2015. Seventy-four patients who were current marijuana users were case matched to 74 nonusers in a 1:1 scheme based on age, sex, and tumor subsite. All patient demographic and QOL data were collected prospectively, and data analysis was conducted from November 1 to December 1, 2017. The QOL outcome was assessed using the EuroQol-5D (EQ5D) and the Edmonton Symptom Assessment System (ESAS) questionnaires. A total of 148 patients were included in this study: 74 in the marijuana user group (mean [SD] age, 62.3 [10.3] years; male sex, 61 patients [82%]) and 74 in the marijuana nonuser group (mean age, 62.2 years; male sex, 63 patients [85%]). There was no statistically significant difference in age, sex, tumor subsite, clinical TNM staging, treatment modality, or mean Karnofsky score between the 2 groups. On univariate analysis, there was no statistically significant difference in the mobility, self-care, and usual activities domains of the EQ5D. Marijuana users had significantly lower scores in the anxiety/depression (difference, 0.74; 95% CI, 0.557-0.930) and pain/discomfort (difference, 0.29; 95% CI, 0.037-1.541) domains. Wilcoxon rank sum test confirmed the results of the EQ5D with improvements in the pain/discomfort (z score, -2.60) and anxiety/depression (z score, -6.71) domains. Marijuana users had less pain, were less tired, were less depressed, were less anxious, had more appetite, were less drowsy, and had better general well-being according to the ESAS. A Wilcoxon rank sum test confirmed a statistically significant improvement in ESAS scores within the domains of anxiety (z score, -10.04), pain (z score, -2.36), tiredness (z score, -5.02), depression (z score, -5.96), drowsiness (z score, -5.51), appetite (z score, -4.17), and general well-being (z score, -4.43). This prospective case-matched study suggests that there may be significant QOL benefits, including decreased anxiety, pain, and depression and increased appetite and generalized feelings of well-being, associated with marijuana use among patients with newly diagnosed HNC.

Single incision multiport versus conventional laparoscopic inguinal hernia repair: A matched comparison

Background:The popularity of single-incision procedures is on the rise as wound cosmesis is increasingly being seen as an important body image-related outcome. In this study, we assess the potential benefits of single-incision multiport laparoscopic totally extra-peritoneal (S-TEP) without using specialised ports or instruments and compare the same with the conventional laparoscopic TEP (C-TEP) surgery in terms of operative time, post-operative pain, complications, cost and cosmesis.Materials and Methods:This is a prospective case-matched study of the patients undergoing S-TEP versus C-TEP from June 2014 to December 2015.Results:Each group had 36 patients. The two groups were comparable in the clinical characteristics. The mean duration of surgery for a unilateral hernia in C-TEP and S-TEP was 45.13 ± 10.58 min and 72.63 ± 15.23 min, respectively. The mean visual analogue scale (VAS) score for pain was significantly higher in S-TEP group at post-operative day (POD) 0 and 1. However, at POD 7, there was no significant difference between the groups. At 1st and 6-week post-surgery, the cosmetic results were significantly better in S-TEP group as compared to C-TEP, however, at 6 months, the scar was highly acceptable in both treatment groups.Conclusion:S-TEP, using conventional laparoscopic instruments, is safe and feasible even in resource challenged setting. However, there is a need to review the indications and advantages of single-incision laparoscopic surgery, as no difference in cosmetic outcome by VAS score in S-TEP versus conventional laparoscopic arm seen by the end of 1 month.

Pathophysiology of fecal incontinence in obese patients: A prospective case-matched study of 201 patients.

Obesity is an emerging risk factor for fecal incontinence (FI). The aim of this study was to characterize pathophysiologic mechanisms of FI in obese patients compared with non-obese patients in a prospective case-matched study. The general characteristics and data of the anorectal manometry and endosonography of patients who were evaluated for FI at a single institution from 2005 to 2015 were prospectively assessed. Fecal incontinence was defined by a Cleveland Clinic Incontinence Score (CCIS) >4. Obesity was defined by a body mass index ≥30kg/m2 . Obese patients were case-matched with two age- and sex-matched non-obese patients. A total of 201 patients were included (67 obese matched with 134 non-obese). The CCIS, Knowles-Eccersley-Scott Symptom Constipation Score and quality of life score were comparable between obese and non-obese patients with FI. Factors significantly associated with obesity in FI patients were cholecystectomy (odds ratio [OR]=3.45 [1.19-10.32], P=.0230), irritable bowel syndrome - diarrhea (OR=2.94 [1.22-7.19], P=.0158), upper part of the anal canal resting pressure ≥22mmHg (OR=3.45 [1.45-8.76], P=.0045), maximum rectal tolerable volume ≥240mL (OR=3.14 [1.34-7.54], P=.0082), and abdominal pressure ≥28mmHg (OR=2.75 [1.13-7.33], P=.0248) by multivariate analysis. Obese patients with FI had a comparable severity of FI to that of non-obese patients with FI. Regarding obesity in patients with FI, physicians should focus on stool consistency.

Labor Analgesia Consumption and Time to Neuraxial Catheter Placement in Women With a History of Surgical Correction for Scoliosis: A Case-Matched Study

(Anesth Analg. 2015;121:981–987) Though neuraxial analgesic techniques are known to be more effective than other types of labor analgesia, some small studies in the past have shown these techniques to be only effective in 50% to 66% of patients who have undergone surgical correction for scoliosis. Although it has become easier to access the epidural space due to recent developments in surgical interventions for scoliosis, the effectiveness of neuraxial labor analgesia can still be diminished by postsurgical scarring and adhesions. The authors sought to carry out a prospective case-matched study to compare the rate of bupivacaine consumption and time to placement of neuraxial technique between laboring women with and without a history of spinal instrumentation.

Labor Analgesia Consumption and Time to Neuraxial Catheter Placement in Women with a History of Surgical Correction for Scoliosis

Neuraxial analgesic techniques are the most effective form of labor analgesia. Small studies (9-21 patients), conducted 10 to 20 years ago, demonstrated successful neuraxial labor analgesia in only 50% to 66% of patients with surgical correction for scoliosis. Newer surgical techniques for scoliosis correction make the epidural space more accessible, but postsurgical changes may still alter the efficacy of neuraxial labor analgesia. The purpose of this prospective case-matched study was to compare hourly bupivacaine consumption and time to placement of neuraxial technique in laboring women with spinal instrumentation compared with women without previous back surgery. All women with previous spinal instrumentation surgery for scoliosis correction who requested neuraxial labor analgesia at Prentice Women's Hospital during the study period were approached. Control subjects were matched for anesthesiologist level of experience. The primary outcomes were bupivacaine consumption per hour of labor analgesia and time to placement of the neuraxial technique. Secondary outcomes included supplemental analgesia requirements and neuraxial analgesia failures and complications. Data from 41 women with surgical correction for scoliosis and 41 control subjects requesting neuraxial labor analgesia were analyzed. Obstetric and demographic characteristics of study participants were not different between groups. Median (interquartile range) hourly bupivacaine consumption was 15.2 mg/h (12.5-18.7) in the spinal instrumentation group and 14.2 mg/h (11.8-16.0) in the control group; the difference in medians was 1 mg/h (95% confidence interval [CI], -1.3 to 3.0; P = 0.38). The total bupivacaine consumption, number of manual reboluses, and number of subjects requiring greater bupivacaine concentrations did not differ between groups. Neuraxial analgesia failure occurred in 5 (12%) of women in the spinal instrumentation group but in none of the control patients (difference [95% CI], 12% [-0.3% to 25%]; P = 0.06). The mean time required to complete the neuraxial technique was 41% (95% CI, 7%-108%; P = 0.01) longer in the spinal instrumentation group than in the control group. The spinal instrumentation group also required a greater number of needle redirections, attempted interspaces, and need to switch to a more experienced provider than matched controls. The findings of this investigation suggest that previous surgery for scoliosis repair does not affect neuraxial labor analgesia consumption, but performance of the neuraxial technique is more difficult. Our findings suggest that neuraxial labor analgesia should be offered to parturients with previous surgery for scoliosis repair although informed consent should include a discussion of the possibility of technical difficulties and surgical anesthesia failure.

Effect of Urate-lowering Therapy on the Risk of Cardiovascular Disease and All-cause Mortality in Patients with Gout: A Case-matched Cohort Study.

To examine (1) the risk of death from cardiovascular disease (CVD) and from all causes in patients with gout who do not undergo urate-lowering therapy (ULT), and (2) the effect of ULT on mortality risk in patients with gout. In this prospective case-matched cohort study, 40,623 Taiwanese individuals aged ≥ 17 years were followed for 6.5 years. Mortality rate was compared between 1189 patients with gout who did not receive ULT and reference subjects (no gout, no ULT) matched for age, sex, and the index date of gout diagnosis (1:3 patients with gout/reference subjects), and between 764 patients with gout who received ULT and 764 patients with gout who did not receive ULT matched 1-to-1 based on their propensity score and the index date of ULT prescription. Cox proportional hazard modeling was used to estimate the respective risk of CVD (International Classification of Diseases, 9th ed. code 390-459) and all-cause mortality. After adjustment, patients with gout not treated with ULT had an increased risk of CVD mortality (HR 2.43, 95% CI 1.33-4.45) and all-cause mortality (1.45, 1.05-2.00) relative to the matched reference subjects (no gout, no ULT). Patients with gout treated with ULT had a lower risk of CVD (0.29, 0.11-0.80) and all-cause mortality (0.47, 0.29-0.79) relative to patients with gout not treated with ULT. This survival benefit persisted for users of either allopurinol or benzbromarone. Patients with gout who received ULT had significantly better survival rates than those who did not. Thus, undertreatment of gout has serious negative consequences.

Gut symptoms in diabetics correlate with components of the rectoanal inhibitory reflex, but not with pudendal nerve motor latencies or systemic autonomic neuropathy.

Fecal incontinence (FI) occurs in up to 20% of diabetes mellitus (DM) patients. Rectoanal inhibitory reflex (RAIR) is an enteric anorectal reflex that reflects the integrity of mechanisms in the physiology of FI. We aimed to investigate whether diabetic patients with FI, not constipation, had prolongation of RAIR and altered gut-specific autonomic tone. In this prospective case-matched study 31 type I DM (19 FI and 12 constipation) and 42 type II DM (26 FI and 16 constipation). Another 21 participants were included as controls. Patients underwent the following assessments: cardiovagal autonomic tone (Modified Mayo Clinic composite autonomic severity score), rectal mucosal blood flow (RMBF) (assessment of gut-specific autonomic tone) and RAIR. Three phases of RAIR and the amplitude of maximal reflex relaxation were compared between groups. All participants completed symptom scores for FI and constipation. RAIR recovery time back to resting pressure was slower in diabetic patients with FI than controls (8.7 s vs 3.6 s, P < 0.05) and was an independent variable correlating with symptoms of FI (P < 0.05). RAIR recovery time was correlated with RMBF (r = 0.58, P = 0.04). RAIR is correlated with anorectal symptoms of FI and was associated with gut-specific autonomic neuropathy.

Comparison of Laparoscopy-Assisted and Open Donor Right Hepatectomy: a Prospective Case-Matched Study from China

BackgroundLaparoscopy-assisted hepatectomy is a new minimally invasive approach for graft harvesting in living donors. Only a few liver transplant centers have introduced this surgical procedure. MethodsA prospective case-matched study was conducted on 25 consecutive donors who underwent laparoscopy-assisted donor right hepatectomy (LADRH) between July 2011 and March 2013 at our transplant center. These donors were matched 1:1 according to age, gender, and body mass index with 25 donors who underwent open donor right hepatectomy (ODRH). ResultsLADRH was successfully performed in all 25 of the donors. Donor complications, estimated blood loss, and operative time were similar between the groups. Hospital stay and periods of analgesic use were significantly shorter in the LADRH group [7.0±1.4 (LADRH) vs 8.7±2.4 (ODRH), p = 0.003, and 2.4±1.0 (LADRH) vs 3.2±1.0 (ODRH), p = 0.011, respectively). The total in-hospital cost is higher with LADRH, primarily due to the additional material costs for LADRH. Finally, there were no differences in graft size, graft survival, or recipient complications between the two groups. ConclusionThe results of this study show that LADRH is a feasible and safe procedure compared with ODRH. Although higher material costs for laparoscopic assisted procedures are inevitable, LADRH may have an advantage over ODRH by causing less pain and facilitating earlier recovery. Efforts can be made to improve the technical success of LADRH for some overweight donors.

Prior abdominal open surgery does not impair outcomes of laparoscopic colorectal surgery: a case–control study in 367 patients

This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS). From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay. A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849). This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

The gentamicin–collagen sponge for surgical site infection prophylaxis in colorectal surgery: a prospective case-matched study of 606 cases

Surgical site infection (SSI) is a major concern in colorectal surgery (CRS). It accounts for 60% of all postoperative complications and has an incidence of between 10 and 30%. The gentamicin-collagen sponge (GCS) was developed to help avoid SSI. The aim of this study was the evaluation of the efficacy of a GCS in preventing SSI after CRS. This study was a retrospective analysis of data collected in a prospective database. Six hundred six CRS patients were enrolled in the study and prospectively assigned to one of two groups. From January 2007 to December 2008, all procedures were performed without the use of GCS (forming the non-GCS group). From January 2009 to July 2011, all procedures included a GCS (forming the GCS group). The primary endpoint was the presence or absence of SSI at postoperative day 30. The incidence of SSI was 29.7 and 20.8% in the non-GCS and GCS groups, respectively (p = 0.019). By using a stepwise logistic regression, the predictors of SSI were found to be ASA grade (p < 0.001), operating time (log-transformed value, p < 0.001), gender (p = 0.021), and GCS use (p < 0.001). By adjusting on these variables, a mean reduction in postoperative hospitalization of 8.3days was found in the GCS group. The proportions of Clavien IIIB-V were 16.6 and 8.9% for the non-GCS and GCS groups, respectively (p = 0.041). This study provides additional evidence of the efficacy of the GCS in reducing SSI rates and shortening hospitalization after CRS.

Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a case-matched study of 180 patients

Background Because it has been suggested that obese patients may be at higher risk of morbidity and mortality after surgery, we conducted a prospective case-matched study to compare outcomes of elective laparoscopic colorectal surgery in obese and nonobese patients. Methods Sixty-two consecutive nonselected obese patients (body mass index ≥30 kg/m 2) were matched with 118 nonobese patients. Postsurgical mortality and morbidity were defined as in-hospital death and complications. Results Cardiopulmonary comorbidities were significantly more frequent in obese compared with nonobese patients (44% vs 24%, P < .01). Obesity was significantly associated with increased mean operating time (268 ± 74 min vs 232 ± 59 min, P < .001), and conversion rate (32% vs 14%, P < .01). The mortality rate was nil. The overall postsurgical morbidity rate (31% vs 19%, P = not significant) and mean hospital stay (11 ± 10 days vs 9 ± 8 days, P = not significant) were similar in obese and nonobese patients. Conclusions The results of this large case-matched study suggest that laparoscopic approach for colorectal surgery is feasible and safe in obese patients.

Upper midline incision for living donor right hepatectomy

Innovations and refinements in the techniques of living donor right hepatectomy (LDRH) have been made over the past decades, but the type and size of abdominal incision have been at a standstill since its inception. We introduce herein the upper midline incision for LDRH using the standard open technique. A prospective case-matched study was conducted on 23 consecutive donors who underwent LDRH under a supraumbilical upper midline incision (I group) from February to May 2008. These donors were matched 1:1 to 23 right liver donors with a conventional J-shaped incision (J group) according to age, gender, and body mass index. Under the mean incision length of 13.5 cm, LDRH was successfully completed in all 23 donors without extension of the incision, with a mean operative time of 232.3 +/- 29.2 minutes. No donors required blood transfusion during surgery. There were 2 cases of postoperative bleeding immediately controlled under the same incision and a case of pleural effusion. All donors fully recovered and returned to their previous activities. All grafts have been functioning well. Compared with the J group, the I group had a shorter operative time, a shorter period of analgesic use, and, after discharge, infrequent complaints of wound pain. This upper midline incision, even without laparoscopic assistance, can be used for LDRH with less pain and without impairing safety, reproducibility, or effectivity, allowing the seemingly insufficient incision to be recommended to the transplant centers that are practicing living donor liver transplantation.

Robotic-assisted Versus Laparoscopic Cholecystectomy

To compare safety and costs of robotic-assisted and laparoscopic cholecystectomy in patients with symptomatic cholecystolithiasis. Technical benefits of robotic-assisted surgery are well documented. However, pressure is currently applied to decrease costs, leading to restriction of development, and implementation of new technologies. So far, no convincing data are available comparing outcome or costs between computer assisted and conventional laparoscopic cholecystectomy. A prospective case-matched study was conducted on 50 consecutive patients, who underwent robotic-assisted cholecystectomy (Da Vinci Robot, Intuitive Surgical) between December 2004 and February 2006. These patients were matched 1:1 to 50 patients with conventional laparoscopic cholecystectomy, according to age, gender, American Society of Anesthesiologists score, histology, and surgical experience. Endpoints were complications after surgery (mean follow-up of 12.3 months [SD 1.2]), conversion rates, operative time, and hospital costs (ClinicalTrial.gov ID: NCT00562900). No minor, but 1 major complication occurred in each group (2%). No conversion to open surgery was needed in either group. Operation time (skin-to-skin, 55 minutes vs. 50 minutes, P < 0.85) and hospital stay (2.6 days vs. 2.8 days) were similar. Overall hospital costs were significantly higher for robotic-assisted cholecystectomy $7985.4 (SD 1760.9) versus $6255.3 (SD 1956.4), P < 0.001, with a raw difference of $1730.1(95% CI 991.4-2468.7) and a difference adjusted for confounders of $1606.4 (95% CI 1076.7-2136.2). This difference was mainly related to the amortization and consumables of the robotic system. Robotic-assisted cholecystectomy is safe and, therefore, a valuable approach. Costs of robots, however, are high and do not justify the use of this technology considering the lack of benefits for patients. A reduction of acquisition and maintenance costs for the robotic system is a prerequisite for large-scale adoption and implementation.

Laparoscopic Colorectal Surgery in Elderly Patients: A Matched Case-Control Study in 178 Patients

We conducted a prospective case-matched study to compare outcomes of laparoscopic colorectal surgery in elderly (>or= 70 years) and younger (< 70 years) patients. Among 506 consecutive patients who underwent 536 colorectal resections supervised by 1 colorectal surgeon (YP), 75 elderly patients (>or= 70 years)were matched with 103 younger patients (< 70 years), according to gender, body mass index, pathology, and surgical procedure. Postoperative mortality and morbidity were defined as in-hospital deaths and complications. One hundred seventy-eight patients (95 men and 83 women) underwent laparoscopic colorectal resection for colorectal carcinoma (40%) or benign diseases (60%). Laparoscopic surgical procedures included left colectomy (43%), rectal resection (34%), right colectomy (12%), subtotal colectomy (6%), and rectopexy (5%). Cardiopulmonary comorbidities were significantly more frequent in elderly compared with young patients (80% versus 33%, p < 0.001). Mean operating times were similar between elderly and young patients (244+/-89 minutes versus 242+/-80 minutes, NS). Thirty-two patients (18%, 16 in each group) required conversion to laparotomy. There was no mortality. Overall postoperative complications were comparable between groups (32% versus 26%, NS). Sixteen patients (9%, 5 elderly and 11 young) required reoperation. Mean hospital stay was comparable between groups (11+/-8 days versus 10+/-9 days, NS). This large case-matched study suggested that laparoscopic colorectal surgery may be proposed in elderly patients, with similar postoperative outcomes as this surgery has in young patients, despite significantly more frequent cardiorespiratory comorbidities.

Prospective, case‐matched study of heated and humidified carbon dioxide insufflation in laparoscopic colorectal surgery

Laparoscopic colorectal surgery is often prolonged and may cause hypothermia. It is uncertain if heated and humidified carbon dioxide (CO(2)) in laparoscopic colorectal surgery is beneficial. This is a prospective case-matched study on the use of heated and humidified CO(2) in patients undergoing laparoscopic colorectal surgery. Twenty consecutive patients undergoing laparoscopic colorectal surgery with heated (36 degrees C) and humidified (95%) CO(2) were compared with 20 consecutive patients using standard CO(2) (30.2 degrees C). All procedures were performed by a single surgeon in an institution. The changes in core temperature during surgery, visual quality of images and the short-term clinical outcome were documented. The core temperature fell during surgery in both groups. Although the fall of core temperature was more in the control group, it was not statistically significant (P > 0.05). The passage of flatus was more delayed in heated and humidified group (P = 0.004), but it did not affect the hospital discharge. All the other parameters, including the quality of visual images and the postoperative pain, were similar in both groups. Despite better temperature maintenance (nonsignificant), pneumoperitoneum using heated and humidified CO(2) gas did not appear to have any clinical benefits in laparoscopic colorectal surgery.