Publications by authors named "Toyooki Sonoda"

38 Publications

Endoscopic stabilization device evaluation using IDEAL framework: A quality improvement study.

Int J Surg 2019 Jul 5;67:18-23. Epub 2019 Mar 5.

Weill Cornell Medicine, New York Presbyterian Hospital, Department of Gasteroenterology, Department of Surgery, 641 Lexington Ave, New York, NY, 10022, USA. Electronic address:

Objective: To determine whether clinical evaluation reporting using the IDEAL (Idea, Development, Exploration, Assessment and Long-term study) framework improves a novel double-balloon endoscopic stabilization technology.

Design: Observational registry 6 month study with no follow-up. Using the Prospective Development Study (PDS) format recommended by the IDEAL collaboration, we report on continued refinement and optimization of an endoscopic stabilization platform during a clinical study conducted by two clinicians from the first case onwards. Key outcomes (ability to reach cecum, inflation of balloons in the sigmoid and ascending colon, and complications) were prospectively reported for each patient sequentially. All changes to technique were highlighted, showing when they occurred and an explanation for the change.

Results: 30 colonoscopies were undertaken using the device from April to September 2017. Two patients were excluded from the analysis for protocol deviations. Cecum was reached in 89% of the per protocol population of patients in an average time of 13.5 ± 11 min. Therapeutic zone creation was successful in 89% of patients on the right side of the intestine and 100% in those that reached the sigmoid. There were five deliberate changes in technique that occurred during the study that enabled improved device technical performance. There were no serious complications and one polyp was removed successfully using the device. Clinicians reported endoscope stability and increased visibility of the intestinal mucosa increased when using the device.

Conclusion: The IDEAL framework provided a structured reporting of the changes made to technique. Those changes facilitated a device that is safe, has achieved stability with improved performance.
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http://dx.doi.org/10.1016/j.ijsu.2019.02.010DOI Listing
July 2019

Double-balloon platform-assisted rectal endoscopic submucosal dissection.

Endoscopy 2018 09 28;50(9):E252-E253. Epub 2018 Jun 28.

Division of Gastroenterology & Hepatology, New York Presbyterian-Weill Cornell Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1055/a-0606-4862DOI Listing
September 2018

A Rare Case of Interdigitating Dendritic Cell Sarcoma of the Rectum: Review of Histopathology and Management Strategy.

BMJ Case Rep 2017 Aug 7;2017. Epub 2017 Aug 7.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Interdigitating dendritic cell sarcoma (IDCS) is a rare neoplasm arising from a subclass of dendritic cells, known for their role in mediating various immunological functions, including T-cell mediated immunity. Although existing literature on IDCS is limited to scattered reports, extranodal manifestation in the gastrointestinal tract, and in particular, the rectum is extremely rare. To our knowledge, we report only the second case of IDCS arising in the rectum in a young 20-year-old man, successfully managed surgically and with a good oncological outcome. Existing literature on the incidence, pathophysiology and treatment strategies is also examined.
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http://dx.doi.org/10.1136/bcr-2017-221754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747786PMC
August 2017

Readmission After Ileostomy Creation: Retrospective Review of a Common and Significant Event.

Ann Surg 2017 02;265(2):379-387

*Memorial Sloan Kettering Cancer Center, New York, NY †Weill Cornell Medical College, New York, NY.

Objective: To evaluate causes and predictors of readmission after new ileostomy creation.

Background: New ileostomates have been reported to have higher readmission rates compared with other surgical patients, but data on predictors are limited.

Methods: A total of 1114 records at 2 associated hospitals were reviewed to identify adults undergoing their first ileostomy. Primary outcome was readmission within 60 days of surgery. Multiple logistic regression was used to identify independent predictors; area under the receiver-operator characteristic curves (AUC) were used to evaluate age-stratified models in secondary analysis.

Results: In all, 407 patients underwent new ileostomy; 58% had cancer, 31% IBD; 49% underwent LAR, 27% colectomy, and 14% proctocolectomy. Median length of stay was 8 days. Among the patients, 39% returned to hospital, and 28% were readmitted (n = 113) at a median of 12 days postdischarge. The most common causes of readmission were dehydration (42%), intraperitoneal infections (33%), and extraperitoneal infections (29%). Dehydration was associated with later, longer, and repeated readmission. Independent significant predictors of readmission were Clavien-Dindo complication grade 3 to 4 [odds ratio (OR) 6.7], Charlson comorbidity index (OR 1.4 per point), and loop stoma (OR 2.2); longer length of stay (OR 0.5) and age 65 years or older (OR 0.4) were protective. Cohort stratification above or below age 65 revealed that older patient readmissions were more predictable (AUC 0.84) with more preventable causes, whereas younger patient readmissions were difficult to predict or prevent (AUC 0.65).

Conclusions: Readmissions are most commonly caused by dehydration, and are predicted by serious complications, comorbidity burden, loop stoma, shorter length of stay, and age. Readmissions in older patients are easier to predict, representing an important target for improvement.
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http://dx.doi.org/10.1097/SLA.0000000000001683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397251PMC
February 2017

An Assessment of the Industry-Faculty Surgeon Relationship Within Colon and Rectum Surgical Training Programs.

J Surg Educ 2016 Jul-Aug;73(4):595-9. Epub 2016 Mar 7.

Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.

Introduction: Industry funding of surgical training programs poses a potential conflict of interest. With the recent implementation of the Sunshine Act, industry funding can be more accurately determined.

Objective: To determine the financial relationship between faculty surgeons within colon and rectal fellowship programs and industry.

Design: Review of industry funding based on the first reporting period (August-December, 2013) using the Centers for Medicare and Medicaid Services online database.

Setting: ACGME certified colon and rectum surgical fellowship programs.

Participants: Overall, 343 Faculty surgeons from 55 colon and rectum surgical fellowship programs were identified using the American Board of Colon and Rectum Surgery website. There was complete identification of faculty surgeons in 47 (85.5%) programs, partially complete identification (i.e., >80%) in 6 (10.9%) programs, and inadequate identification of faculty in 2 (3.6%) programs.

Main Outcome: Industry funding as defined by the Sunshine Act included general payments (honorariums, consulting fees, food and beverage, and travel), research payments, and amount invested.

Results: In all, 69.1% of program directors and 59.4% of other faculty received at least one payment during the reporting period (Δ9.7%, 95% CI: -4.4% to 23.8%, p = 0.18). Program directors received higher amounts of funding than other faculty ($7072.90 vs. $2,819.29, Δ$4,253.61, 95% CI: $1132-$7375, p = 0.008). Overall, 49 of 53 (93%) programs had surgeons receive funding, with a median of 3.5 surgeons receiving funding per program. A total of 65 companies made payments to surgeons, with 80.1% of the funding categorized as general payments, 16.2% as investments, and 3.7% as research payments.

Conclusions: Industry funding was common. This financial relationship poses a potential conflict of interest in training fellows for future practice.
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http://dx.doi.org/10.1016/j.jsurg.2016.01.013DOI Listing
March 2017

Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study.

J Laparoendosc Adv Surg Tech A 2015 Sep;25(9):737-43

1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York.

Background: High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy.

Materials And Methods: A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons.

Results: Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels.

Conclusions: Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.
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http://dx.doi.org/10.1089/lap.2014.0603DOI Listing
September 2015

Prospective multicenter study of a synthetic bioabsorbable anal fistula plug to treat cryptoglandular transsphincteric anal fistulas.

Dis Colon Rectum 2015 Mar;58(3):344-51

1 Department of Surgery, University of California, Irvine, Irvine, California 2 Department of Surgery, Weill-Cornell-Houston Methodist, Houston, Texas 3 Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 4 Department of Surgery, Mount Sinai School of Medicine, New York, New York 5 Department of Surgery, Rush University Medical Center, Chicago, Illinois 6 Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania 7 Department of Surgery, Weill Medical College, Cornell University, New York, New York 8 Department of Surgery, University of Illinois, Chicago, Illinois.

Background: Although interest in sphincter-sparing treatments for anal fistulas is increasing, few large prospective studies of these approaches have been conducted.

Objective: The study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug.

Design: A prospective, multicenter investigation was performed.

Setting: The study was conducted at 11 colon and rectal centers.

Patients: Ninety-three patients (71 men; mean age, 47 years) with complex cryptoglandular transsphincteric anal fistulas were enrolled. Exclusion criteria included Crohn's disease, an active infection, a multitract fistula, and an immunocompromised status.

Intervention: Draining setons were used at the surgeon's discretion. Patients had follow-up evaluations at 1, 3, 6, and 12 months postoperatively.

Main Outcome Measures: The primary end point was healing of the fistula, defined as drainage cessation plus closure of the external opening, at 6 and 12 months. Secondary end points were fecal continence, duration of drainage from the fistula, pain, and adverse events during follow-up.

Results: Thirteen patients were lost to follow-up and 21 were withdrawn, primarily to undergo an alternative treatment. The fistula healing rates at 6 and 12 months were 41% (95% CI, 30%-52%; total n = 74) and 49% (95% CI, 38%-61%; total n = 73). Half the patients in whom a previous treatment failed had healing. By 6 months, the mean Wexner score had improved significantly (p = 0.0003). By 12 months, 93% of patients had no or minimal pain. Adverse events included 11 infections/abscesses, 2 new fistulas, and 8 total and 5 partial plug extrusions. The fistula healed in 3 patients with a partial extrusion.

Limitations: The study was nonrandomized and had relatively high rates of loss to follow-up.

Conclusion: Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure.
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http://dx.doi.org/10.1097/DCR.0000000000000288DOI Listing
March 2015

Laparoscopic resection of t4 colon cancers: is it feasible?

Dis Colon Rectum 2015 Jan;58(1):25-31

Section of Colon and Rectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, New York.

Background: Laparoscopic surgical treatment of T4 cancers remains a concern that is mostly associated with technical feasibility, high conversion rate, inadequate oncologic clearance, and surgical outcome.

Objective: The purpose of this work was to evaluate the short- and long-term clinical and oncologic outcomes after laparoscopic and open surgeries for T4 colon cancers.

Design: This was a retrospective study of patients with T4 colon cancer without metastasis (M0) who had laparoscopic or open surgery from 2003 to 2011.

Setting: The study was conducted at a single institution.

Patients: A total of 83 patients with pT4 colon cancer were included.

Main Outcome Measures: R0 resection rate, morbidity and mortality within 30 postoperative days, overall survival, and disease-free survival were measured.

Results: Laparoscopic surgery was performed on 61 and open surgery on 22 patients. The groups were similar in overall staging (p = 0.461), with 35 (42%) of the patients at stage 2 and 48 (58%) at stage 3. A complete R0 resection was achieved in 61 (100%) of the patients who underwent laparoscopic surgery and in 21 (96%) of the patients who underwent open surgery (p = 0.265). The average number of lymph nodes harvested was 21 in the laparoscopic group and 24 in the open group (p = 0.202). Thirty-day morbidity rate was similar between the groups (p = 0.467), and the mortality rate was 0. The length of hospital and postsurgical stay was significantly shorter in the laparoscopic group (p = 0.002 and p = 0.008). The 3-year overall survival rates between the groups were 82% (range, 71%-93%) for patients who underwent laparoscopic surgery and 81% (range, 61%-100%) for those who underwent open surgery (p = 0.525), and disease-free survival was 67% (range, 54%-79%) for laparoscopic surgery and 64% (range, 43%-86%) for open surgery (p = 0.848). The follow-up time was 40 ± 25 in months in the laparoscopic group and 34 ± 26 months in the open surgery group (p = 0.325).

Limitations: This was a retrospective study at a single institution.

Conclusions: The study shows that laparoscopic surgery is feasible in T4 colon cancers. With comparable clinical and oncologic outcomes, this study suggests that laparoscopy may be considered as an alternative approach for T4 colon cancers with the advantage of faster recovery (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A156).
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http://dx.doi.org/10.1097/DCR.0000000000000220DOI Listing
January 2015

Accuracy of CT enterography and magnetic resonance enterography imaging to detect lesions preoperatively in patients undergoing surgery for Crohn's disease.

Dis Colon Rectum 2014 Dec;57(12):1364-70

Section of Colon and Rectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, New York.

Background: CT enterography and magnetic resonance enterography have emerged as first-line imaging technologies for the evaluation of the gastrointestinal tract in Crohn's disease.

Objective: The purpose of this work was to evaluate the accuracy of these imaging modalities to identify Crohn's disease lesions preoperatively.

Design: This was a retrospective chart review.

Settings: The study was conducted at a single institution.

Patients: Seventy-six patients with Crohn's disease with preoperative CT enterography and/or magnetic resonance enterography were included in the study.

Main Outcome Measures: The number of stenoses, fistulas, and abscesses on CT enterography and/or magnetic resonance enterography before surgery were compared with operative findings.

Results: Forty patients (53%) were women, 46 (60%) underwent surgery for recurrent Crohn's disease, and 46 (57%) had previous abdominal surgery. Thirty-six (47%) had a preoperative CT enterography and 43 (57%) had a preoperative magnetic resonance enterography. CT enterography sensitivity was 75% for stenosis and 50% for fistula. MRE sensitivity was 68% for stenosis and 60% for fistula. The negative predictive values of CT enterography and magnetic resonance enterography for stenosis were very low (54% and 65%) and were 85% and 81% for fistula. CT enterography had 76% accuracy for stenosis and 79% for fistula; magnetic resonance enterography had 78% accuracy for stenosis and 85% for fistula. Both were accurate for abscess. False-negative rates for CT enterography were 50% for fistula and 25% for stenosis. False-negative rates for magnetic resonance enterography were 40% for fistula and 32% for stenosis. Unexpected intraoperative findings led to modification of the planned surgical procedure in 20 patients (26%).

Limitations: This study was limited by its small sample size, its retrospective nature, and that some studies were performed at outside institutions.

Conclusions: CT enterography and magnetic resonance enterography in patients with Crohn's disease were accurate for the identification of abscesses but not for fistulas or stenoses. Surgeons should search for additional lesions intraoperatively. Patients should be appropriately counseled regarding the need for unexpected interventions (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A162).
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http://dx.doi.org/10.1097/DCR.0000000000000244DOI Listing
December 2014

Reply to letter: "identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients".

Ann Surg 2015 Apr;261(4):e94-5

Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY Department of Biostatistics, Cornell University, Ithaca, NY Hospital for Special Surgery, New York, NY Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY Department of Medicine, Weill Cornell Medical College, New York, NY Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY.

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http://dx.doi.org/10.1097/SLA.0000000000000231DOI Listing
April 2015

Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps.

Dis Colon Rectum 2013 Jul;56(7):869-73

New York Presbyterian Hospital, Weill-Cornell Medical College, New York, New York, USA.

Background: Patients with large benign colon polyps not amenable to endoscopic removal commonly undergo resections. Polyp removal using combined endolaparoscopic surgery may be an effective alternative to bowel resection in select patients.

Objective: The aim of this study was to evaluate short-term and long-term outcomes of patients who underwent endolaparoscopy at our institution.

Data Sources: Medical records and a prospectively maintained database were reviewed.

Study Selection: This study constituted a retrospective review of consecutive patients who underwent endolaparoscopy for benign polyps from 2003 to 2012.

Interventions: Combined endolaparoscopic surgery was performed.

Main Outcome Measures: The primary outcomes measured were success rate, rate of recurrence, rate of malignancy, length of stay, and complication rate.

Results: A total of 75 patients were taken to the operating room with the intention of endolaparoscopy. The most common indications were large polyp size and difficult location. Based on intraoperative findings, 10 patients were suspected of having cancer and underwent immediate laparoscopic colectomy. Of 65 attempted cases, 48 patients (74%) underwent successful combined endolaparoscopic surgery. Median follow-up time was 65 (8-87) months. Patients in whom combined endolaparoscopic surgery was unsuccessful were converted to colectomy (2 open, 15 laparoscopic). Two patients were converted because of concerns of cancer and 15 because of technical difficulties. Median operative time for successful endolaparoscopy was 145 (50-249) minutes. The complication rate was 4.4% (2/48). Median length of stay was 1 (0-6) day for endolaparoscopy vs 5 (3-19) days for those converted to colectomy. Median polyp size was 3 (1.0-7.0) cm. One patient was found to have cancer on final pathology, but refused to have further surgery. Sensitivity and specificity of predicting malignancy based on clinical findings were 33% (4/12) and 98.5% (64/65). Four of 5 patients who had recurrence (10%) after endolaparoscopy had complete endoscopic polypectomy. One patient required delayed laparoscopic colectomy for a second recurrence.

Limitations: This study was limited by its retrospective nature.

Conclusions: Combined endolaparoscopic surgery appears to be a safe and effective alternative to colectomy in all parts of the colon in patients who have benign polyps not removable with colonoscopy alone.
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http://dx.doi.org/10.1097/DCR.0b013e3182821e58DOI Listing
July 2013

Improved access and visibility during stapling of the ultra-low rectum: a comparative human cadaver study between two curved staplers.

Ann Surg Innov Res 2012 Nov 13;6(1):11. Epub 2012 Nov 13.

Saint Catherine of Siena Medical Center, Smithtown, NY, USA.

Unlabelled:

Background: The purpose of this study was to compare in human cadavers the applicability of a commonly used stapling device, the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH) to a newly released, curved stapler, the Endo GIA™ Radial Reload with Tri-Staple™ Technology (RR) (Covidien, New Haven, CT) METHODS: Four experienced surgeons performed deep pelvic dissection with total mesorectal excision (TME) of the rectum in twelve randomized male cadavers. Both stapling devices were applied to the ultra-low rectum in coronal and sagittal configurations. Extensive measurements were recorded of anatomic landmarks for each cadaver pelvis along with various aspects of access, visibility, and ease of placement for each device.

Results: The RR reached significantly lower into the pelvis in both the coronal and sagittal positions compared to the CC. The median distance from the pelvic floor was 1.0 cm compared to 2.0 cm in the coronal position, and 1.0 cm versus 3.3 cm placed sagitally, p < 0.0001. Surgeons gave a higher visibility rating with less visual impediment in the sagittal plane using the RR Stapler. Impediment of visibility occurred in only 10% (5/48) of RR applications in the coronal position, compared to a rate of 48% (23/48) using the CC, p = 0.0002.

Conclusions: The RR device performed significantly better when compared to the CC stapler in regards to placing the stapler further into the deep pelvis and closer to the pelvic floor, while causing less obstructing of visualization.
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http://dx.doi.org/10.1186/1750-1164-6-11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539907PMC
November 2012

Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients.

Ann Surg 2013 Jan;257(1):108-13

Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, NY 10065, USA.

Objective: The purpose of this study was to identify patient, clinical, and surgical factors that may predispose patients to anastomotic leak (AL) after large bowel surgery.

Background: Anastomotic leak is still one of the most devastating complications following colorectal surgery. Knowledge about factors predisposing patients to AL is vital to its early detection, decision making for surgical time, managing preoperative risk factors, and postoperative complications.

Methods: This was a prospective observational, quality improvement study in a cohort of 616 patients undergoing colorectal resection in a single institution with the main outcome being AL within 30 days postoperatively. Some of the predictor variables were age, sex, Charlson Comorbidity Index (CCI), radiation and chemotherapy, immunomodulator medications, albumin, preoperative diagnoses, surgical procedure(s), surgical technique (laparoscopic vs open), anastomotic technique (staple vs handsewn), number of major arteries ligated at surgery, surgeon's experience, presence of infectious condition at surgery, intraoperative adverse events, and functional status using 36-Item Short Form General Health Survey.

Results: Of the 616 patients, 53.4% were female. The median age of the patients was 63 years and the mean body mass index was 25.9 kg/m. Of them, 80.3% patients had laparoscopic surgery and 19.5% had open surgery. AL occurred in 5.7% (35) patients. In multivariate analysis, significant independent predictors for leak were anastomoses less than 10 cm from the anal verge, CCI of 3 or more, high inferior mesenteric artery ligation (above left colic artery), intraoperative complications, and being of the male sex.

Conclusions: Multiple risk factors exist that predispose patients to ALs. These risk factors should be considered before and during the surgical care of colorectal patients.
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http://dx.doi.org/10.1097/SLA.0b013e318262a6cdDOI Listing
January 2013

Evaluation of the safety, efficacy, and versatility of a new surgical energy device (THUNDERBEAT) in comparison with Harmonic ACE, LigaSure V, and EnSeal devices in a porcine model.

J Laparoendosc Adv Surg Tech A 2012 May 24;22(4):378-86. Epub 2012 Feb 24.

Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, New York, New York 10065, USA.

Background: THUNDERBEAT™ (TB) (Olympus, Japan) simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. The aim of this study was to evaluate the versatility, bursting pressure, thermal spread, and dissection time of the TB compared with commercially available devices: Harmonic(®) ACE (HA) (Ethicon Endo-Surgery, USA), LigaSure™ V (LIG) (Covidien, USA), and EnSeal(®) (Ethicon).

Methods: An acute study was done with 10 female Yorkshire pigs (weighing 30-35 kg). Samples 2 cm long of small (2-3 mm)-, medium (4-5 mm)-, and large (6-7 mm)-diameter vessels were created. One end of the sample was sent for histological evaluation, and the other was used for burst pressure testing in a blinded fashion. Versatility was defined as the performance of the surgical instrument based on the following five variables, using a score from 1 to 5 (1=worst, 5=best), adjusted by coefficient of variable importance with weighted distribution: hemostasis, 0.275; histologic sealing, 0.275; cutting, 0.2; dissection, 0.15; and tissue manipulation, 0.1. There were 80 trials per vessel group and 60 trials per instrument group, giving a total of 240 samples.

Results: Versatility score was higher (P<.01) and dissection time was shorter (P<.01) using TB compared with the other three devices. Bursting pressure was similar among TB and the other three instruments. Thermal spread at surgery was similar between TB and HA (P=.4167), TB and EnSeal (P=.6817), and TB and LIG (P=.8254). Difference in thermal spread was noted between EnSeal and HA (P=.0087) and HA and LIG (P=.0167).

Conclusion: TB has a higher versatility compared with the other instruments tested with faster dissection speed, similar bursting pressure, and acceptable thermal spread. This new energy device is an appealing, safe alternative for cutting, coagulation, and tissue dissection during surgery and should decrease time and increase versatility during surgical procedures.
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http://dx.doi.org/10.1089/lap.2011.0420DOI Listing
May 2012

Isolated splenic metastasis from rectal carcinoma: a rare occurrence.

Case Rep Oncol 2011 Sep 4;4(3):499-504. Epub 2011 Sep 4.

Departments of Medicine, Weill Cornell Medical College, New York, N.Y., USA.

The presence of isolated splenic metastasis in rectal carcinoma is uncommon and usually presents as an asymptomatic mass, noted incidentally on imaging. Splenectomy is usually performed with the goal of curing metastatic disease. It is unclear if adjuvant chemotherapy affords any benefit, and the prognosis is unknown. The case of a young woman is reported, in whom an isolated metastatic lesion in the spleen was discovered 9 months after adjuvant chemotherapy for stage III rectal adenocarcinoma. The patient has remained disease-free for nearly 5 years following splenectomy and chemotherapy. To our knowledge, this is the fourth reported case in the English literature of an isolated splenic metastatic lesion from rectal cancer. We discuss the unique presentation, the importance of post-treatment surveillance, and the implementation of multi-modality treatment strategies in this young patient.
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http://dx.doi.org/10.1159/000333446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220905PMC
September 2011

The impact of incidental identification on the stage at presentation of lower gastrointestinal carcinoids.

J Am Coll Surg 2011 Nov 31;213(5):652-6. Epub 2011 Aug 31.

Department of Surgery, Weill Cornell Medical College-NewYork Presbyterian Hospital, New York, NY, USA.

Background: Over the past 3 decades, there has been a significant increase in the incidence of gastrointestinal carcinoid tumors in the United States. Incidentally discovered carcinoids in the lower gastrointestinal tract have probably contributed to this increase. In this study we aimed to compare the clinicopathologic characteristics of incidentally discovered carcinoids of the small and large bowel with those identified as a result of symptoms.

Study Design: We performed a retrospective review of 58 consecutive patients with nonappendiceal gastrointestinal carcinoids: 30 small bowel and 28 large bowel. We compared asymptomatic patients with lower gastrointestinal tract carcinoids identified by routine colonoscopy with those identified as a result of symptoms.

Results: Twenty-eight (48.3%) incidentally identified carcinoids (15 small bowel and 13 large bowel) were compared with 30 (51.7%) symptomatic carcinoids. Incidental ileal carcinoids were similar in size (mean ± SD, 1.3 ± 0.61 vs 1.7 ± 1.13, p = 0.45) and incidence of lymph node metastases (12 in 15 vs 9 in 15, p = 0.43) to symptomatic ileal carcinoids. However, incidental ileal carcinoids had a lower incidence of distant metastases (1 in 15 vs 7 in 15, p = 0.035) compared with symptomatic ileal carcinoids. There was no difference in tumor size, extent of lymph node metastases, or distant metastases between incidental and symptomatic large bowel carcinoids.

Conclusions: Ileal carcinoids identified at screening colonoscopy are associated with a significantly decreased incidence of distant metastases compared with those identified after development of symptoms, despite similar size and extent of lymph node metastases. However, incidental large bowel carcinoids appear to have similar staging to those identified as a result of symptoms.
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http://dx.doi.org/10.1016/j.jamcollsurg.2011.07.021DOI Listing
November 2011

Stapler access and visibility in the deep pelvis: A comparative human cadaver study between a computerized right angle linear cutter versus a curved cutting stapler.

Ann Surg Innov Res 2011 Aug 27;5. Epub 2011 Aug 27.

Department of Surgery, Weill Medical College of Cornell University, New York, NY, USA.

Purpose: Distal rectal stapling is often challenging because of limited space and visibility. We compared two stapling devices in the distal rectum in a cadaver study: the iDrive™ right angle linear cutter (RALC) (Covidien, New Haven, CT) and the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH).

Methods: Twelve male cadavers underwent pelvic dissection by 4 surgeons. After rectal mobilization as in a total mesorectal excision, the staplers were applied to the rectum as deep as possible in both the coronal and sagittal positions. The distance from the pelvic floor was measured for each application. A questionnaire rated the visibility and access of the stapling devices. Measurements were taken between pelvic landmarks to see what anatomic factors hinder the placement of a distal rectal stapler.

Results: The median (range) distance of the stapler from the pelvic floor in the coronal position for the RALC was 1.0 cm (0-4.0) vs. 2.0 cm (0-5.0) for the CC, p = 0.003. In the sagittal position, the median distance was 1.6 cm (0-3.5) for the RALC and 3.3 cm (0-5.0) for the CC, p < 0.0001. The RALC scored better than the CC in respect to: 1. interference by the symphysis pubis, 2. number of stapler readjustments, 3. ease of placement in the pelvis, 4. impediment of visibility, 5. ability to hold and retain tissue, 6. visibility rating, and 7. access in the pelvis. A shorter distance between the tip of the coccyx and the pubic symphysis correlated with a longer distance of the stapler from the pelvic floor (p = 0.002).

Conclusions: The RALC is superior to the CC in terms of access, visibility, and ease of placement in the deep pelvis. This could provide important clinical benefit to both patient and surgeon during difficult rectal surgery.
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http://dx.doi.org/10.1186/1750-1164-5-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3189175PMC
August 2011

Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery.

Surg Infect (Larchmt) 2011 Aug 26;12(4):255-60. Epub 2011 Jul 26.

Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York 10065, USA.

Background: Surgical site infections (SSIs) cause morbidity after elective colorectal surgery, and antibiotic prophylaxis can decrease SSIs. The aim of this study was to determine compliance with an antibiotic administration protocol, including regimen, initial dose timing, and re-dosing, and determine the risk of SSI associated with each. We hypothesized that appropriate antibiotic administration reduces the risk of SSI.

Methods: Retrospective review from a prospective database of a random sample of patients undergoing elective abdominal colorectal procedures with anastomosis. Antibiotic regimens, initial dose timing (IDT), and re-dosing were evaluated. Appropriate regimens covered gram-positive cocci, gram-negative bacilli, and anaerobes. The IDT was considered proper if completed within 30 min prior to incision; re-dosing parameters were determined pharmacokinetically for each agent. The main outcome was SSI. Sequential logistic models were generated: Model 1 assessed antibiotic administration factors, whereas Model 2 controlled for patient and clinical factors, including disease process, patient characteristics, intra-operative factors, and post-operative factors.

Results: Six hundred five patients (mean age 59.7 [standard deviation 17.8] years, 42.8% male) were included. The most common diagnoses were cancer (38.8%) and inflammatory bowel disease (22.0%). Seventy-six patients (12.6%) had superficial or deep incisional SSI, and 54 (8.9%) had organ/space SSI. Regimens included cefazolin + metronidazole for 219 patients (36.2%), cefoxitin for 214 (35.4%), and levofloxacin + metronidazole for 48 (7.9%). One hundred fourteen patients (18.8%) received other/nonstandard regimens, and ten had no documented antibiotic prophylaxis. Fifty-five patients (9.1%) received insufficient coverage, whereas 361 patients (59.7%) had proper IDT, and 401 regimens (66.3%) were re-dosed properly. In Model 1, the use of other/nonstandard regimens (odds ratio [OR] 2.069; 95% confidence interval [CI] 1.078-1.868) and early administration of the initial prophylaxis dose (OR 1.725; 95% CI 1.147-2.596) were associated with greater odds of SSI. After adding clinical factors in Model 2, both of these factors remained significant (OR 2.505; 95% CI 1.066-5.886 and OR 1.733; 95% CI 1.017-2.954, respectively).

Conclusions: Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of SSI after elective colorectal surgery with intestinal anastomosis.
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http://dx.doi.org/10.1089/sur.2010.073DOI Listing
August 2011

Differing risk factors for incisional and organ/space surgical site infections following abdominal colorectal surgery.

Dis Colon Rectum 2011 Jul;54(7):818-25

Department of Surgery, Weill Cornell Medical College, New York, New York 10065, USA.

Objective: Surgical site infections are a major source of morbidity after colorectal surgery. The aim of this study was to explore differences between incisional and organ/space surgical site infection types by evaluating risk factors, National Nosocomial Risk Index Scores, and clinical outcomes.

Design: A random sample of adults undergoing abdominal colorectal surgery between June 2001 and July 2008 was extracted from a colorectal surgery practice database. Patient factors, comorbidities, intraoperative factors, postoperative factors, and infection were collected; risk score (from -1 to 3 points) was calculated. Variables associated with surgical site infection by univariate analysis were incorporated in a multivariable model to identify risk factors by infection type. Infection risk by risk score was evaluated by logistic regression. Length of stay, readmission, and mortality were examined by infection type.

Results: Six hundred fifty subjects were identified: 312 were male, age was 59.8 (SD 17.8) years. Common preoperative diagnoses included colorectal cancer (36.9%) and inflammatory bowel disease (21.7%). Forty-five cases were emergencies, and 171 included rectal resections. Eighty-two patients developed incisional and 64 developed organ/space surgical site infections. Body mass index was associated with incisional infection (OR 1.05, 95% CI 1.00-1.09), whereas previous radiation (OR 4.49, 95% CI 1.53-13.18), postoperative hyperglycemia (OR 2.99, 95% CI 1.41-6.34), preoperative [albumin] (OR 0.52, 95% CI 0.36-0.76), and case length (OR 1.26, 95% CI 1.08-1.47) were associated with organ/space infection. A risk score of 2 and above, compared with a score of <2, predicted organ/space (OR 5.92, 95% CI 3.16-11.09) but not incisional infection (OR 0.95, 95% CI 0.41-2.16). Organ/space infections were associated with longer length of stay (P = .006) and higher readmission rates (P < .001) than incisional infections.

Conclusions: Risk factors for surgical site infections differ by type of infection. Clinical outcomes and value of the risk index score are different by infection type. It may be prudent to consider incisional and organ/space surgical site infections as different entities for patients undergoing colorectal surgery.
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http://dx.doi.org/10.1007/DCR.0b013e3182138d47DOI Listing
July 2011

Endoscopic fixation of the rectum for rectal prolapse: a feasibility and survival experimental study.

Surg Endosc 2011 Nov 4;25(11):3691-7. Epub 2011 Jun 4.

Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.

Background: In recent years, there has been considerable interest in developing technology as well as techniques that could widen the therapeutic horizons of endoscopy. Rectal prolapse, a benign localized condition causing considerable morbidity, could be an excellent focus for new endoscopic therapies. The aim of this study was to assess the feasibility and safety of endoluminal fixation of the rectum to the anterior abdominal wall, after pushing it up inside the body, using an in vivo animal model.

Methods: We performed an in vivo comparative surgical study in a porcine model, including laparoscopic mobilization of the rectum and posterior rectopexy (standard surgical method) or endoluminal tacking of the rectum. After proving feasibility in ex vivo and acute studies, we performed a survival study to evaluate the safety of endoluminal tacking of the mobilized rectum to the anterior abdominal wall. The main outcome measures were successful completion of the tasks, maintenance of the fixation, complications associated with the methods, and survival studies including histopathological examinations of the fixation sites.

Results: There were two groups: laparoscopic rectopexy (8 animals) and endoluminal fixation of the rectum to the anterior abdominal wall (10 animals). There were no differences between these two groups in their postoperative recovery. The group with the endoluminal fixation was found to have adequate attachment of the rectum to the anterior abdominal wall (measured attachment pressure in the endoluminal group = 6.06 ± 0.52 ft-lb, in the control group = 4.86 ± 2.00 ft-lb) on both gross and microscopic evaluation.

Conclusion: Endoscopic fixation of the mobilized rectum is feasible and safe in this model and in the future may provide an effective alternative to current treatment options for rectal prolapse.
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http://dx.doi.org/10.1007/s00464-011-1778-yDOI Listing
November 2011

Physiologic effects of simultaneous carbon dioxide insufflation by laparoscopy and colonoscopy: prospective evaluation.

Surg Endosc 2011 Oct 24;25(10):3279-85. Epub 2011 May 24.

Department of Surgery, Weill Cornell Medical College, New York, NY 10065, USA.

Background: The use of intraoperative carbon dioxide (CO(2)) colonoscopy during a laparoscopic colon operation is becoming more common. Simultaneous intracolonic and intraabdominal CO(2) insufflation may result in significant physiologic changes, but in-depth physiologic effects have not been studied to date. This study aimed to evaluate the physiologic changes and the overall safety of simultaneous CO(2) laparoscopy and colonoscopy.

Methods: A prospective pilot study was performed with 26 subjects (17 men and 9 women) undergoing laparoscopic surgical treatment for colorectal conditions adjunctively managed with CO(2) intraoperative colonoscopy. Surgery proceeded with CO(2) insufflation to a maximum pressure of 12 mmHg by laparoscopy and with a maximum CO(2) flow of 5 l/min via colonoscopy. Serial intra- and postoperative arterial blood gases, end-tidal CO(2), and minute ventilation were recorded during predetermined periods: during initial laparoscopy, during simultaneous colonoscopy and laparoscopy, during laparoscopy after colonoscopy, and after desufflation.

Results: No significant morbidity resulted from simultaneous CO(2) insufflation. Three patients had a CO(2) partial pressure (PaCO(2)) greater than 50, and one patient with a body mass index (BMI) higher than 42 kg/m(2) had a PaCO(2) greater than 50 for more than 30 min and was compensated by increasing minute ventilation. The mean pH was 7.36 in the recovery room. Postoperatively, no patient had a pH lower than 7.3, prolonged intubation, or reintubation.

Conclusion: Simultaneous CO(2) colonoscopy and laparoscopy lead only to transient alterations in respiratory parameters that can be compensated. Based on these findings, simultaneous insufflation of CO(2) into the peritoneal cavity and the large bowel lumen during complex endoscopic procedures may be considered safe for most patients.
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http://dx.doi.org/10.1007/s00464-011-1705-2DOI Listing
October 2011

Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach.

Dis Colon Rectum 2011 Jun;54(6):753-8

Section of Colon and Rectal Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York 10065, USA.

Background: For complex right colon polyps, not removable using colonoscopy, right colon resection is considered the optimal treatment. Combined endoscopic-laparoscopic surgery, using both laparoscopy and CO2 colonoscopy, has been introduced as a new approach for these complex colon polyps with intent to avoid bowel resection.

Objective: This study aimed to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery used for treatment of complex right colon polyps.

Design: This is a retrospective study of patients undergoing combined endoscopic-laparoscopic surgery for treatment of benign right colon polyps from 2003 to 2008.

Settings: This is a single-institution study.

Patients: Twenty-three patients with complex right colon polyps were included.

Main Outcome Measures: The main outcome measures included the length of hospital stay, postoperative complications, and polyp recurrence.

Results: Of 23 patients, 20 (87%) patients had their polyp removed successfully by combined endoscopic-laparoscopic surgery and 3 (13%) needed laparoscopic resection, after laparoendoscopic evaluation. The median length of hospital stay was 2 days (range, 1-5), and there were no postoperative complications. Median follow-up time was 12 months. Three patients had recurrent polyps, and the recurrence-free interval at 36 months was 55.7% (95% CI = 8.6%, 87.0%). All recurrences were benign polyps and were removed by colonoscopic snaring.

Conclusions: Combined endoscopic-laparoscopic surgery can be safely offered to selected patients with benign right colon polyps that can not be removed by colonoscopy. This combined approach may provide a viable alternative to right colon resection for complex benign colon lesions and warrants future investigation.
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http://dx.doi.org/10.1007/DCR.0b013e3182108289DOI Listing
June 2011

Gastrointestinal recovery after laparoscopic colectomy: results of a prospective, observational, multicenter study.

Surg Endosc 2010 Mar 18;24(3):653-61. Epub 2009 Aug 18.

Division of Colorectal Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA.

Background: Although evidence suggests that laparoscopic colectomy (LC) results in faster gastrointestinal (GI) recovery than open bowel resection, previous studies were performed at single institutions or generally not controlled for diet introduction or perioperative care, making the results difficult to interpret. A prospective, observational, multicenter study was planned to investigate GI recovery, length of hospital stay (LOS), and postoperative ileus (POI)-related morbidity after LC.

Methods: Patients scheduled to undergo LC or hand-assisted laparoscopic (HAL) bowel resection and to receive opioid-based postoperative intravenous patient-controlled analgesia were enrolled in 16 U.S. centers. The study design was similar to that for trials of alvimopan phase 3 open laparotomy bowel resection using a standardized accelerated postoperative care pathway. The primary end points were time to upper and lower GI recovery (GI-2: toleration of solid food and bowel movement) and postoperative LOS. The secondary end points included POI-related morbidity (postoperative nasogastric tube insertion or investigator-assessed POI resulting in prolonged hospital stay or readmission), conversion rate, and protocol-defined prolonged POI (GI-2 > 5 postoperative days).

Results: In this study, 148 patients received hemicolectomy by the LC (42 left and 67 right) or HAL (39 left) approach. The conversion rate was 18.8% (25.4% LC left, 17.3% HAL left, 15% LC right). The mean time to GI-2 recovery was 4.4 days, and the mean postoperative LOS was 4.9 days, neither of which varied substantially by surgical approach. Prolonged POI occurred for 15 patients (10.1%), and POI-related morbidity occurred for 17 patients (11.5%). No patients were readmitted because of POI, whereas 3 patients (2%) were readmitted for all other causes.

Conclusions: Mean GI recovery and LOS after LC were accelerated compared with those for patients in open laparotomy bowel resection clinical trials or those reported in large hospital databases (0.7 and 1.7-2.2 days, respectively). Overall POI-related morbidity was similar between the open bowel resection and LC populations, demonstrating that POI continues to present with important morbidity regardless of the surgical approach.
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http://dx.doi.org/10.1007/s00464-009-0652-7DOI Listing
March 2010

Long-term outcomes of patients undergoing curative laparoscopic surgery for mid and low rectal cancer.

Dis Colon Rectum 2009 Jul;52(7):1215-22

New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA.

Purpose: The use of laparoscopy surgery in the management of rectal cancer is controversial, especially in the mid and low rectum. The aim of this study was to determine oncologic and long-term outcomes after laparoscopic and hand-assisted laparoscopic surgery for mid and low rectal cancer.

Methods: Between January 1999 and December 2006, 185 patients had surgery for rectal cancer; 103 these patients had mid and low rectal cancer. The source of data was inpatient/outpatient medical records. Telephone interviews were conducted for all patients. Actuarial survival was calculated with use of the Kaplan-Meier method.

Results: Hand-assisted laparoscopic surgery was performed in 58 (56.3%) patients, and pure laparoscopic surgery in 45 (43.7%) patients. Mean follow-up time was 42.1 months. The conversion rate was 2.9%. All specimen margins were negative. The anastomotic leak rate was 7.8% (n = 8). There was no 30-day mortality. Local recurrence rate was 5% at five years. Overall survival was 91% and disease-free survival was 73.1% at five years.

Conclusion: Laparoscopic surgical techniques for mid and low rectal cancer seem safe and feasible with acceptable oncologic and long-term outcomes. Further studies, comparing laparoscopic and open methods, are warranted.
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http://dx.doi.org/10.1007/DCR0b013e3181a73e81DOI Listing
July 2009

Longterm complications of hand-assisted versus laparoscopic colectomy.

J Am Coll Surg 2009 Jan 31;208(1):62-6. Epub 2008 Oct 31.

Section of Colon and Rectal Surgery, Weill Medical College of Cornell University, New York, NY, USA.

Background: Hand-assisted laparoscopic surgery (HALS) requires a larger incision compared with standard laparoscopic surgery (SLS). Whether this leads to more longterm complications, such as incisional hernia (IH) and small bowel obstruction (SBO), has not been studied to date. This study compares the rates of SBO and IH after HALS and SLS in patients undergoing operations for colon and rectal diseases.

Study Design: From a colorectal database, 536 consecutive patients were identified who underwent bowel resection using HALS (n = 266) and SLS (n = 270) between 2001 to 2006. All medical records were reviewed, and all subjects were contacted by telephone for accurate followup. Statistical analysis was performed using chi-square, Fisher's exact, and Mann-Whitney U tests, where appropriate.

Results: Median followup was 27 months (range 1 to 72 months). Overall conversion rate was 2.2% (SLS, n = 4; HALS, n = 8). Median incision size in HALS (75 mm; range 60 to 140 mm) was larger than SLS (45 mm; range 30 to 130 mm; p < 0.01). Despite the larger wound, the incidence of IH was similar between both approaches (HALS, n = 16 [6.0%] versus SLS, n = 13 [4.8%]; p < 0.54). Rate of SBO was also comparable (HALS, n = 11 [4.1%] versus SLS, n = 20 [7.4%]; p = 0.11). Wound infections occurred similarly between both groups (HALS, n = 18 [6.8%]; SLS, n = 13 [4.8%]; p = 0.33). Converted patients had a higher rate of IH compared with nonconverted ones (25% versus 5%; p = 0.02), although the rate of SBO was similar (8.3% versus 5.7%; p = 0.51).

Conclusions: HALS does not lead to more longterm complications of IH and SBO when compared with SLS for resections of the colon and rectum.
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http://dx.doi.org/10.1016/j.jamcollsurg.2008.09.003DOI Listing
January 2009

Does prior abdominal surgery influence conversion rates and outcomes of laparoscopic right colectomy in patients with neoplasia?

Dis Colon Rectum 2008 Nov 12;51(11):1669-74. Epub 2008 Jul 12.

Department of Surgery, New York-Presbyterian Hospital, New York, New York, USA.

Purpose: The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy.

Methods: A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm.

Results: Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted (P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history (P < 0.0001).

Conclusions: Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy.
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http://dx.doi.org/10.1007/s10350-008-9278-4DOI Listing
November 2008

Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial.

Dis Colon Rectum 2008 Jun 17;51(6):818-26; discussion 826-8. Epub 2008 Apr 17.

Department of Colon & Rectal Surgery, Lahey Clinic, 41 Mall Road, Burlington, Massachusetts 01805, USA.

Purpose: This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery.

Methods: Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups.

Results: There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 +/- 58 vs. 208 +/- 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 +/- 31 vs. 184 +/- 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68).

Conclusions: In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy.
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http://dx.doi.org/10.1007/s10350-008-9269-5DOI Listing
June 2008

Endometriosis causing ileocecal intussusception.

Gastrointest Endosc 2008 Feb;67(2):352-3

Division of Gastroenterology and Hepatology, Weill Cornell Medical School, New York, NY, USA.

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http://dx.doi.org/10.1016/j.gie.2007.08.034DOI Listing
February 2008

Expediting of laparoscopic rectal dissection using a hand-access device.

Dis Colon Rectum 2007 Jun;50(6):927-9

Department of Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY 10021, USA.

Adoption of laparoscopic rectal dissection has been limited partially because of technical difficulties related to rectal exposure and effective retraction. We introduce a simple but effective method of retracting the distal rectum by using a Gelport hand-assisted laparoscopic device. Our method facilitates laparoscopic rectal dissection while obviating the need for intracorporeal manual retraction.
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http://dx.doi.org/10.1007/s10350-007-0239-0DOI Listing
June 2007
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