Mission Statement

Surgery Group of Los Angeles Research Foundation is dedicated to the prevention and the elimination of disabling and life-threatening illnesses through clinical research and education.
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Research Interns

The Surgery Group of Los Angeles Research Foundation currently has
ten ongoing longitudinal studies:

Background:

Flap procedures following excision of recurrent or complex pilonidal sinus disease (PSD) are associated with relatively high wound complication rate.

Background:
Hartmann’s procedure, colonic resection with an end colostomy and rectal closure, is commonly performed in patients with colonic obstruction and/or perforation. Hartmann’s reversal or colostomy closure is associated with significant technical difficulty and morbidity. High grade evidence studies related to Hartmann’s reversal are scarce. We sought to better gauge the complexity of outcome of Hartmann’s reversal by comparing it to left colectomy, a common elective operation with similar resultant left sided colonic anastomosis. As such, we examine the short-term outcomes of Hartmann’s reversal (HR) and left colectomy (LC) for cancer (LCC) and diverticulitis (LCD).

Background:

Patients with locally advanced rectal cancer (LARC) with a significant response to preoperative radiotherapy/chemoradiotherapy have significantly better survival compared to non-responders. It is not known, however, how well responders fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We hypothesized that LARC downstaged to pathologic stage 0-1 disease has better survival compared to true pathologic stage 0-1 tumors.

Introduction:

Perioperative chemotherapy is the standard of care for most patients with resectable gastric adenocarcinoma. We hypothesized that patients with cT2N0 cancers undergoing upfront surgery and adjuvant therapy have similar outcomes to those receiving pre or perioperative chemotherapy.

Background:

The FOxTROT trial suggested that preoperative chemotherapy may provide a potential benefit in patients with operable colon cancer. We examined the survival benefit of preoperative chemotherapy in patients with resected, non-metastatic colon cancer using a large nationwide cohort. We hypothesized that preoperative chemotherapy would provide a small survival benefit over postoperative chemotherapy.

Background:

Mucinous neoplasms of the appendix (MNAs) are rare and relatively little is known about their behavior. We sought to determine predictors of lymph node positivity and identify patients that may benefit from right hemicolectomy (RHC).

Background:

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of minimally invasive RC and LC for cancer, with subanalysis of robotic techniques.

Objective:

Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding

Purpose:

The oncologic outcomes of right sided cancers are generally grouped in studies. We hypothesized that tumor location (cecal vs. ascending vs. hepatic flexure) may influence cancer specific outcomes.

Background:

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters.

Background:

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of minimally invasive RC and LC for cancer, with subanalysis of robotic techniques.)

Research Publications

For information about enrollment in one of our research projects please contact us at: (310) 289-1518

Prospective Registry Study evaluating ovine forestomach matrix graft as part of pilonidal sinus flap reconstruction – Interim analysis

Purpose/Background
Flap procedures following excision of recurrent or complex pilonidal sinus disease (PSD) are associated with relatively high wound complication rate.

Hypothesis/Aim
Given the inflammation and contamination associated with PSD, we hypothesized that the addition of an ovine forestomach matrix graft to our existing bilateral gluteal fasciocutaneous advancement flap may help reduce wound complications.

Methods/Interventions
This is an interim analysis of a single site in an ongoing prospective registry study evaluating the safety and efficacy of an ovine forestomach matrix (OFM) graft across a range of surgical procedures (ClinicalTrials.gov Identifier: NCT05243966). The OFM graft (Myriad Matrix™) is an FDA-cleared biologic implant, which provides a scaffold for cell re-population and rapidly forms well vascularized tissue and is remodeled over time.
Following elliptical excision of pilonidal disease, gluteal fasciocutaneous advancement flaps were elevated circumferentially. Prior to closure, a hydrated OFM graft was placed in the surgical dead space above the pre-coccygeal fascia. The flaps were approximated with interrupted sutures incorporating the OFM graft. A surgical drain was then placed in the subcutaneous space followed by midline closure of the dermal layer with interrupted absorbable sutures. Two full thickness retention sutures tied over a rolled-up gauze were placed at the inferior portion of the midline incision. The primary outcome for the study were device related adverse events, wound complications, and time (weeks) to complete healing.

Results/Outcomes
A total of 9 (8 males) patients with a mean age of 26 (range: 21-35) years and mean BMI of 28.2 (range: 23.2-35.9) were included. Mean follow up was 13 weeks (range:4-27). Seven (77.8%) patients had complete healing at their 1 month follow up. The mean time to complete healing was 6.5 weeks (range:4-16). There were two superficial wound dehiscences that occurred before the 1-month post op visit and one superficial wound dehiscence that occurred after the 1-month follow. All three healed without any need for subsequent surgery. There were no post-procedural infections, hematoma/seroma formation or device related adverse events. Four (44.4%) patients achieved a 3 month follow up with an average patient scar satisfaction score of 4.8 on a 1-5 scale.
Limitations
This study is an interim analysis of an ongoing long term registry study with a limited sample size.

Conclusion
The addition of the OFM graft to reconstruction of PSD wound was safe and had low rate of wound complications and high satisfaction with scar cosmesis. A larger analysis will be completed at the conclusion of the study.

Hartmann’s Reversal is More Complex than Elective Left Colectomy

Background:
Hartmann’s procedure, colonic resection with an end colostomy and rectal closure, is commonly performed in patients with colonic obstruction and/or perforation. Hartmann’s reversal or colostomy closure is associated with significant technical difficulty and morbidity. High grade evidence studies related to Hartmann’s reversal are scarce. We sought to better gauge the complexity of outcome of Hartmann’s reversal by comparing it to left colectomy, a common elective operation with similar resultant left sided colonic anastomosis. As such, we examine the short-term outcomes of Hartmann’s reversal (HR) and left colectomy (LC) for cancer (LCC) and diverticulitis (LCD).

Methods:
A retrospective review of a prospective database was performed. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. Student’s t-test and Pearson’s chi-squared test were used for continuous and categorical variables. The Mann-Whitney U test was used to analyze the differences in the distributions of complications on a continuous scale.

Results:
Between January 2014 and March 2021, 114 patients were included: 27 HR and 87 LC (41 LCC and 46 LCD). There were no significant differences between HR and LC in age (64.7 vs. 60.0, p=0.18), gender (48.1% vs. 52.9% male, p=.67), mean BMI (27.1 vs. 28.4, p=.38), mean robotic time (138.0 vs. 97.6, p=0.06), and mean estimated blood loss (97.0 vs. 87.9 mL, p=.62). There were significantly higher mean ASA scores (2.67 vs. 2.43, p=.04) and mean Charlson Comorbidity Index scores (5.07 vs. 3.32, p=.02) in HR than LC.

There were significantly more open cases in HR than LC (22.2% vs. 2.3%, p<.0005) and fewer robotic cases (44.4% vs. 69.0%, p=.02). Total operative time was significantly longer in HR than LC (258.7 vs. 209.6 mins, p=0.02). There were significantly more intraoperative complications in HR than LC (14.8% vs 2.3%, p=0.01). There were no significant differences between HR and LC in overall postoperative complications per patient (0.85 vs. 0.54, p=.27), rates of ileus/small bowel obstruction (SBO) (25.9% vs. 17.2%, p=.32), and superficial or deep wound infections (11.1% vs. 6.9%, p=.48). Although not significant, the mean length of stay (LOS) was longer (9.00 vs 6.89 days, p=.17), and the 30-day readmission rate was higher in HR than LC (14.8% vs. 5.7%, p=.13). Time to first flatus/bowel movement was significantly longer in HR than LC (3.59 vs. 2.51 days, p<.005).

We performed subgroup analyses for HR vs. LCC and HR vs. LCD. In the HR vs. LCC comparison, there were no significant differences in demographics or comorbidities. Mean robotic console time and total operative time were longer in HR than LCC. There were no significant differences in post-operative outcomes. Time to first flatus/bowel movement was significantly longer in HR than LCC.

In the HR vs. LCD comparison, there were no significant differences in demographics. HR patients had significantly higher mean total ASA scores, Charlson Comorbidity Index scores, more open cases, and longer total operative time. There were no significant differences in intraoperative complications or postoperative outcomes. Time to first flatus/bowel movement was significantly longer in HR than LCC.

Conclusion:
Hartmann’s reversal is a more complex surgical procedure compared with left colectomy. Careful patient selection and surgical planning is important for favorable surgical outcomes.

Downstaging After Preoperative Chemoradiation for Locally-Advanced Rectal Cancer is Associated with better survival than pathologic stage 0-1 disease treated with upfront surgery.

Background:

Patients with locally advanced rectal cancer (LARC) with a significant response to preoperative radiotherapy/chemoradiotherapy have significantly better survival compared to non-responders. It is not known, however, how well responders fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We hypothesized that LARC downstaged to pathologic stage 0-1 disease has better survival compared to true pathologic stage 0-1 tumors.

Methods:

The NCDB (2004-2016) was queried for all patients with non-metastatic rectal cancer who had undergone radical resection. Three distinct study groups were identified: 1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after preoperative radiotherapy, 2) clinical stage 2-3 disease not downstaged after radiotherapy, and 3) true pathologic 0-1 tumors treated with upfront surgery. Demographic, clinical, and pathologic factors were compared. Overall survival was compared using Kaplan-Meier and multivariate Cox-regression analyses.

Results:

59,884 patients were identified. The mean age of the population was 61.6 ±12.7 years and 61% of the population was male. Of the 40,130 patients (67%) with LARC treated with preoperative radiation, 31.5% (12,670) had significant downstaging (group 1) while 27,460 had no significant downstaging (group 2). 19,754 (33%) had pathologic 0-1 disease treated with upfront resection (group 3). 96% of patients in groups 1 and 2 received chemotherapy prior to surgery, indicating a predominant long-course chemoradiation strategy. Group 3 patients were significantly older than groups 1 and 2 (65.2 ± 0.09 vs. 60.5 ± 0.11 and 59.6 ± 0.07 years, respectively). Group 1 patients had the lowest rate of LVI (4.2% vs. 22.7% and 9.7% in groups 2 and 3, respectively). Non-downstaged (group 2) patients had the highest rate of margin positivity (8.5% vs. 1.9% and 1.1% for groups 1 and 3, respectively) (all p<0.001). On Kaplan-Meier analysis, downstaged patients (group 1) had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median OS 156 vs. 99 and 136 months for groups 2 and 3, respectively, p<0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p<0.001) compared to true pathologic 0-1 patients, while non-downstaged patients fared significantly worse (HR 1.78, p<0.001).

Conclusion:

LARC down staged after preoperative radiotherapy/chemoradiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis. Our results also suggest that multidisciplinary therapy may be superior to surgery alone, even for early-stage patients.

Upfront Surgery with Adjuvant Therapy is equivalent to surgery with preoperative and perioperative chemotherapy in patients with clinical T2N0 gastric adenocarcinoma

Introduction:

Perioperative chemotherapy is the standard of care for most patients with resectable gastric adenocarcinoma. We hypothesized that patients with cT2N0 cancers undergoing upfront surgery and adjuvant therapy have similar outcomes to those receiving pre or perioperative chemotherapy.

Methods:

The National Cancer Database was used to identify all patients with cT2N0M0 invasive gastric adenocarcinoma who underwent radical gastrectomy. Patients were categorized into 3 treatment groups: 1) pre/perioperative chemotherapy, 2) postoperative chemotherapy and 3) postoperative chemoradiation. Overall survival was compared using the Kaplan-Meier method and multivariate Cox-regression analysis, controlling for relevant pre-treatment and operative confounding factors.

Results:

4002 patients met inclusion criteria. The mean age was 67.2 ± 12.4 years, 2554 (64%) were male, 2168 (54%) had high-grade disease and 48% had appropriate lymphadenectomy (≥15 nodes). 61%, 20%, 15% and 3% had final pathologic stage I, II, III and IV disease, respectively. 482 (12%) of patients underwent pre/perioperative chemotherapy, 246 (6%) had postoperative chemotherapy, 585 (15%) underwent postoperative chemoradiation. There was no significant difference in age, comorbidity, tumor grade, and margin status among treatment groups. Patients undergoing preoperative treatment had lower final pathologic stage compared to the postoperative chemotherapy and chemoradiation groups (78%, 58% and 65% pathologic stage I disease, respectively, p<0.05). Patients undergoing postoperative chemoradiation had a lower rate of appropriate lymphadenectomy (55%) compared to preoperative (61%) and postoperative (64%) chemotherapy (p<0.05). Kaplan Meier analysis and multivariate Cox regression analysis controlling for age, comorbidity, grade and nodal harvest demonstrated no significant differences in overall survival in the 3 treatment groups.

Conclusion:

Patients with clinical T2N0 gastric adenocarcinoma who undergo upfront surgery with adjuvant therapy have similar overall survival compared to those who undergo preop/perioperative chemotherapy.

Preoperative Chemo is Associated with Worse Overall Survival inOperable Colon Cancer

Purpose/Background:

The FOxTROT trial suggested that preoperative chemotherapy may provide a potential benefit in patients with operable colon cancer. We examined the survival benefit of preoperative chemotherapy in patients with resected, non-metastatic colon cancer using a large nationwide cohort. We hypothesized that preoperative chemotherapy would provide a small survival benefit over postoperative chemotherapy.
Methods/Interventions: The NCDB database (2004-2016) was queried for all patients with non-metastatic colon adenocarcinoma, treated with radical resection and chemotherapy in whom clinical stage was known. Treatment groups were categorized into preoperative vs. post-operative chemotherapy. Demographic, clinical and pathologic factors were compared between treatment groups. Because pretreatment EUS or MRI are not routinely performed for colon cancer, patients were broadly categorized into those with clinical localized disease (stages 1-2) and those with clinical nodal disease (stage 3). Overall survival was compared using the Kaplan Meier method stratified by clinical nodal status, and multivariate Cox-regression analysis controlling for confounding factors including age, comorbidity, clinical stage, and regional nodes examined.


Results/Outcome(s):

49,255 patients were identified. The mean age of the population was 62.6 ± 12.5 years. 24,738 patients (50.2%) had clinical nodal disease. 1509 patients (3.1%) received preoperative chemotherapy, while the remainder (96.9%) received postoperative chemotherapy. Patients receiving preoperative chemotherapy were younger (60.4 ± 0.31 vs. 62.7 ± 0.06 yrs, preop vs. postop, respectively), more likely to be male (61% vs. 50%), had less comorbidity (80% vs. 74% Charlson-Deyo 0), lower grade disease (83% vs. 75% Grade 1-2), less clinical stage 3 disease (42% vs. 51%), less pathologic stage 3 disease (37% vs. 76%) and lower mean lymph node harvest (17.8 ± 0.11 vs. 20.8 ± 0.04) (all p-values <0.05). On Kaplan Meier analysis, preoperative chemotherapy was associated with significantly worse overall survival (median OS 100 vs. 136 months, preop vs. postop, respectively, p<0.05). On stratified analysis, this difference was most pronounced in patients with clinical node negative disease. On multivariate analysis, preoperative chemotherapy was a significant independent predictor of worse overall survival (HR 1.5, p<0.001).


Conclusions/Discussion:

Preoperative chemotherapy is associated with worse survival compared to postoperative chemotherapy in patients with operable colon cancer, particularly in clinically node-negative disease. This finding may be secondary to delay in surgery in the preoperative therapy group, or due to more high-risk disease that cannot be accounted for by traditional risk factors. Prospective trials are necessary to evaluate the true benefit of preoperative chemotherapy in operable colon cancer.

Lymph node positivity and the role of right hemicolectomy in patients with mucinous neoplasms of the appendix.

Intro:

Mucinous neoplasms of the appendix (MNAs) are rare and relatively little is known about their behavior. We sought to determine predictors of lymph node positivity and identify patients that may benefit from right hemicolectomy (RHC). 

Methods:

The National Cancer Database (2004-2015) was queried for all patients >18 y/o with non-metastatic mucinous neoplasms of the appendix. Demographic, clinical and pathologic criteria were recorded. Standardized classification schemes were utilized. Univariate and multivariate predictors of lymph node positivity were determined in patients undergoing RHC. Univariate and multivariate survival analyses were performed to determine the impact of RHC on overall survival. 

Results:

3796 patients were identified. 56 (1.8%) patients were classified as low grade mucinous neoplasms, 3 (0.1%) with high grade mucinous neoplasm, 2694 (86.4%) with low grade mucinous adenocarcinoma, and 364 (11.7%) with high grade mucinous adenocarcinoma. 2016 (53.1%) patients underwent RHC. 385 (19.1%) had positive nodes. Margin positivity, LVI, high grade histology, and increasing T-stage were univariate predictors of lymph node positivity (all p<0.01). Tumor size was marginally significant (p=0.51). On multivariate analysis, margin status, grade and LVI remained independent predictors of lymph node positivity. In those with invasive disease, the combination of low-grade, margin negative, no LVI, and T-stage <=2 identified a subset of patients with low risk (6.6% vs. 21.3%) of lymph node positivity. RHC did not improve survival in the overall population or in any subset of grade, classification, LVI, lymph node status, margin status, or T-stage. On multivariate analysis, RHC was not an independent predictor of survival.

Conclusion:

Margin status, LVI and high grade histology are independent predictors of lymph node status in MNA patients. With invasive disease, a low risk subset was identified in whom hemicolectomy can be avoided. Formal hemicolectomy did not improve survival even in high risk subsets, likely because peritoneal disease is a more important determinant of outcome than hematogenous spread.

Bilateral Gluteal Fasciocutaneous Advancement Flaps with and without Tie-Over Sutures in Treatment of Pilonidal Disease

Background:

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of minimally invasive RC and LC for cancer, with subanalysis of robotic techniques.


Methods:

In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student’s t-test and Fisher’s exact Chi-square test were used for continuous and categorical variables, respectively.


Results:

Between January 2014 and August 2020, 115 patients underwent minimally invasive RC or LC for cancer. Sixty-eight RC [30 (44.1%) laparoscopic, 38 (55.9%) robotic] and 47 LC [13 (27.6%) laparoscopic, 34 (72.4%) robotic] cases were included. RC patients were significantly older (71.1 vs. 63.9, p=.007). There were no significant differences between RC and LC in sex, mean ASA score, Charlson Comorbidity Index scores, total operative time, and estimated blood loss. Robotic console time was significantly longer in the RC versus LC group (153.5 vs. 92.9 mins, p<.001), as RC involved intracorporeal anastomosis. RC patients had significantly higher overall postoperative complications (50% vs 30% p=.03), but no differences in rates of ileus/SBO (27.9% vs. 19.1% p=.28) or wound infections (9.0% vs. 4.3% p=.34). There was no difference in time to first flatus/bowel movement (3.0 vs 2.7 days, p=.38), mean length of stay (7.7 vs 6.9 days, p=.47), or in 30-day readmissions (9.0% vs 8.5%, p=.72).
On multivariate analysis, there was no significant difference in overall postoperative complications and laparoscopic surgery had a 2.5 times higher likelihood of complications than robotic surgery (p=.029). In subanalysis of robotic cases, there was no significant difference among all outcome variables.


Conclusion:

Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Provocative Mesenteric Angiography for Localizing Ambiguous Gastrointestinal Hemorrhage

Objective:

Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding.

 

Methods:

This is an IRB-approved, retrospective study of 20 patients who underwent PMA between 2014 and 2019. All patients had clinical evidence of GI hemorrhage without a definite source. PMA consisted of anticoagulation with 5000 units of heparin and selective transcatheter injection of up to 600 micrograms of nitroglycerine, followed by slow infusion of up to 24 milligrams of tissue plasminogen activator (TPA) into the arterial distribution of the highest suspicion mesenteric artery.

 

Results:

Among the 20 patients who underwent PMA, 11/20 (55%) resulted in angiographically visible extravasation. Of these 11 patients, 9 patients underwent successful embolization with coil or glue and were discharged upon achieving hemodynamic stability. Two patients spontaneously stopped bleeding. In our series, PMA resulted in the successful treatment of 9/20 (45%) patients with recurrent hemorrhage. No procedure-associated complications were reported with these 20 patients during the procedure and their course of hospitalization.

 

Conclusions:

In our experience, PMA is an effective and safe approach in localizing and treating the source of GI bleeding in about half of patients with an otherwise unidentifiable source.

The Impact of Tumor Location on Long-Term Survival Outcomes in Patients with Right-Sided Colon Cancer

Purpose:

The oncologic outcomes of right sided cancers are generally grouped in studies. We hypothesized that tumor location (cecal vs. ascending vs. hepatic flexure) may influence cancer specific outcomes.

Methods:

The SEER database was queried for patients over 18 with non-metastatic, invasive (AJCC stage I-III) right-sided adenocarcinoma of the colon from 1988-2014 who underwent partial colectomy.

Patients were categorized into groups: 1) cecum 2) ascending colon 3) hepatic flexure. Demographic, clinical and pathologic factors were compared between groups. Disease specific and overall survival were described using the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox-regression analysis determined the independent association of primary tumor location.

Results:

167,450 patients were identified. Mean age was 72.2 ± 12.3 years and 54.9% were female. Of these, 81,611, 66,857, and 18,982 had cecal, ascending colon, and hepatic flexure cancers, respectively. Cecal cancers were associated with a lower number of examined nodes but a higher likelihood of nodal positivity. Cecal cancer patients were significantly older, had larger tumors, and higher tumor stage. On univariate analysis, cecal cancers were associated with poorer disease specific and overall survival (all p-values <0.001). On multivariate analysis controlling for sex, age, tumor size, number of examined nodes and stage, hepatic flexure cancers were associated with worse disease specific (HR 1.05) and overall survival (HR 1.03).

Discussion:

Hepatic flexure cancers have worse survival compared to more proximal colon cancers. The cause is likely multifactorial, including biological and technical factors. More aggressive surgical and multimodal therapy may be considered for hepatic flexure colon cancers.

Robotic Colorectal Procedures: Does Operative Start Time Impact Short Term Outcome?

Background:

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters.


Methods:

In a retrospective review of a prospective database, 210 robotic colorectal surgeries were grouped into 97 morning versus 113 afternoon cases. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. An independent samples t-test, Fisher’s exact test, and linear regression were used for categorical and continuous variables.


Results:

Morning patients were significantly younger than afternoon patients (59.5 vs. 65.5, p = 0.004), but there were no significant differences in gender, mean BMI, Charlson Comorbidity Index score, total operative time, console time, estimated blood loss, indications for surgery, and resection type. Morning patients had a significantly shorter mean length of stay (6.0 vs. 8.0 days, p = 0.021), but no significant differences in overall postoperative complications (0.30 vs. 0.30, p = 0.715), wound infection (5.2% vs. 7.1%, p = 0.564), anastomotic leak (0% vs. 2.7%, p = 0.251), ileus/small bowel obstruction (29.9% vs. 22.1%, p = 0.199), and 30-day readmission (8.2% vs. 7.1%, p = 1.000). When analyzing time of day as a continuous variable, we found no significant associations with intra- or postoperative complications.


Conclusion:

We found no correlation between surgery start time and intra- or postoperative outcomes. This can be partly attributed to these cases being elective and performed primarily by 2 experienced surgeons with highly trained operating room robotic staff in a large volume tertiary center. This, along with decreased fatigue attributed to superior ergonomics of robotic surgery, may have mitigated previously reported differences between morning and afternoon procedures.

Minimally Invasive Right Versus Left Colectomy for Cancer: Does Robotic Surgery Mitigate Differences in Short Term Outcomes?

Background:

Studies comparing right (RC) and left colectomies (LC) show higher rates of ileus in RC and higher wound infection and anastomotic leak rates in LC. However, prior studies did not include robotic procedures. We compared short-term outcomes of minimally invasive RC and LC for cancer, with subanalysis of robotic techniques.
Methods: In a retrospective review of a prospective database, preoperative factors, intraoperative events, and 30-day postoperative outcomes were compared. Student’s t-test and Fisher’s exact Chi-square test were used for continuous and categorical variables, respectively.


Results:

Between January 2014 and August 2020, 115 patients underwent minimally invasive RC or LC for cancer. Sixty-eight RC [30 (44.1%) laparoscopic, 38 (55.9%) robotic] and 47 LC [13 (27.6%) laparoscopic, 34 (72.4%) robotic] cases were included. RC patients were significantly older (71.1 vs. 63.9, p=.007). There were no significant differences between RC and LC in sex, mean ASA score, Charlson Comorbidity Index scores, total operative time, and estimated blood loss. Robotic console time was significantly longer in the RC versus LC group (153.5 vs. 92.9 mins, p<.001), as RC involved intracorporeal anastomosis. RC patients had significantly higher overall postoperative complications (50% vs 30% p=.03), but no differences in rates of ileus/SBO (27.9% vs. 19.1% p=.28) or wound infections (9.0% vs. 4.3% p=.34). There was no difference in time to first flatus/bowel movement (3.0 vs 2.7 days, p=.38), mean length of stay (7.7 vs 6.9 days, p=.47), or in 30-day readmissions (9.0% vs 8.5%, p=.72).
On multivariate analysis, there was no significant difference in overall postoperative complications and laparoscopic surgery had a 2.5 times higher likelihood of complications than robotic surgery (p=.029). In subanalysis of robotic cases, there was no significant difference among all outcome variables.


Conclusion:

Previously reported outcome differences between laparoscopic RC and LC for cancer may be mitigated by robotic surgery.

Hartmann’s Reversal is More Complex than Elective Left Colectomy

Hartmann’s procedure, colonic resection with an end colostomy and rectal closure, is commonly performed in patients with colonic obstruction and/or perforation. Hartmann’s reversal or colostomy closure is associated with significant technical difficulty and morbidity. High grade evidence studies related to Hartmann’s reversal are scarce. We sought to better gauge the complexity of outcome of Hartmann’s reversal by comparing it to left colectomy, a common elective operation with similar resultant left sided colonic anastomosis. As such, we examine the short-term outcomes of Hartmann’s reversal (HR) and left colectomy (LC) for cancer (LCC) and diverticulitis (LCD).

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