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IN THE NEWS
FIRST LOOK All Articles by CHRISTINA FRANGOU
Living Donor Robotic Kidney Transplant
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DENVER—Surgeons from the Lahey Clinic presented a technique for a living donor robotic kidney transplant, an approach that leads to a speedier recovery for patients and lower wound complication rates. “We have noted excellent wound healing, lower narcotic pain usage and shorter length of hospital stays following our early cohort of robotic kidk ney transplantation recipients,” said Caro-line J. Simon, MD, the senior staff surgeon and fellowship program director at the Lahey Hospital and Medical Center in Burlington, Mass. Graft function after robotic transplantation is similar to that for conventional kidney transplantation, she said. At SAGES, Dr. Simon showed a video e eo of a robotic kidney transplant performed d on a 53-year-old female patient who received a living donor kidney graft from her daughter. To perform the operation, surgeons made five incisions for four robotic ports and two laparoscopic ports, with one GelPort (Applied Medical) used as both a laparoscopic and robotic port. Robotic dissection was used to prepare the iliac vessels for implantation, while waiting for the living donor nephrectomy procurement. The graft was then inserted via the GelPort in the umbilicus, and the robot was used to perform all anastomoses. Total warm ischemia time is around 40 minutes, she said. The technique was first reported in 2010 by Italian surgeons who performed a robotic kidney transplant in a morbidly obese patient, for whom conventional laparoscopic instruments were unsuitable (Am J Transplant 2010;10[6]:1478-1482). Dr. Simon and her colleagues performed their first robotic kidney transplant in January 2020, after adapting the technique from surgeons at Henry Ford Hospital, in Detroit. Since then, they’ve operated on eight patients using the robotic approach. They expect to increase uptake in the next year after early delays due to the COVID-19 pandemic, she said. “We are hoping to have a fairly rapid expansion, as we have seen good preliminary results,” Dr. Simon said. Open kidney transplantation, first performed in 1954, is associated with high rates of incisional hernias, as well as wound dehiscence and surgical site infections. The first laparoscopic kidney transplant was reported by Spanish surgeons in 2010 (Eur Urol 2010;57[1]:164-167). Surgeons at SAGES said the total robotic approach is promising. “I think there’ll be wound benefits, potentially decreased hernia rates. There’s a lot of potential benefits from converting this to a robotic procedure,” said Jacob Greenberg, MD, a professor of surgery at Augusta University, in Georgia.
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Pre-op Bowel Stimulation Reduces Post-op Ileus
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DENVER—A program of preoperative bowel stimulation via the efferent limb of the ileostomy significantly
GENERAL SURGERY NEWS / MAY 2022
The Society of American Gastrointestinal And Endoscopic Surgeons reduced rates of postoperative ileus in patients undergoing elective loop ileostomy closure, according to results from a multicenter, single-blind randomized trial. In the study of 97 patients, only 6% of those who received repeat bowel stimulation in the three weeks before surgery developed postoperative ileus—down from 24.5% of patients in the control arm. “The relative risk reduction with this intervention makes it quite attractive and appealing,” said study co a th co-auth h Richard Garfinkle, MD, a PGY-4 co-author resiid resident in general surgery at Montreal’s M McGill University, during his present tation at SAGES. Investigators recruited adult patients from five hospitals in Canada, one in the United States and another in New Zealand. All p patients previously had a segmentta colectomy or proctectomy with a tal divve diverting loop ileostomy and were randomly assigned to the control or stimulation arm. Patients in the stimulation arm received up to 10 episodes of bowel stimulation performed in an outpatient clinic over the three weeks prior to ileostomy closure. During each session, an 18 Fr Foley catheter was used to intubate the distal limb of the loop of the ostomy, which was infused with a solution of 500 cc of normal saline combined with 30 g of thickening agent. Nearly 80% of patients completed all 10 sessions, 17% completed seven to nine and 4% completed less than seven sessions. Each stimulation lasted an average of 25 minutes, and about 25% of patients reported abdominal cramping. However, only four out of 410 sessions were terminated early due to poor tolerance. There were no major adverse events. Forty-seven percent of patients in the intervention arm had a return of flatus by postoperative day 1, compared with 22.4% in the control arm (P=0.022). Their postoperative length of stay fell to three days, down from four in the control arm (P=0.003). After the presentation, Dimitrios Stefanidis, MD, a professor of surgery at Indiana University School of Medicine, in Indianapolis, called the findings “extremely convincing.” But it’s unclear how many patients would be eligible for this kind of bowel stimulation. The intervention used in the study is time-consuming for both patients and providers and may not be realistic for all patients, Dr. Garfinkle said. As such, he and his colleagues are looking at the potential for patients to perform stimulation at home with the help of community nurses, on their own or with family members, he said. The investigators initially planned to recruit 166 patients, based on sample size calculations indicating that 83 participants would be required in each arm to show a significant effect of bowel stimulation. However, the pandemic affected patient recruitment and study logistics. The investigators performed an interim analysis after 101 patients were randomized. Although the study was stopped early, this remains the largest trial to explore bowel stimulation in these patients and is the first multicenter trial to do so. A 2014 single-center Spanish trial of 70 patients found
ileus fell to 3% from 20% after preoperative bowel stimulation (Dis Colon Rectum 2014;57[12]:1391-1396). The findings are only applicable to patients with residual colon, and not to patients with ileal pouch–anal anastomosis, according to the authors.
U.K.-Based Liver Surgery Scoring System Correlates With U.S. Outcomes DENVER—The Halls/Southampton Laparoscopic Liver Difficulty Score—a model that predicts the risk for intraoperative complications during minimally invasive liver resections—correlates with operative outcomes in North American patients, including estimated blood loss, operative time and length of stay, according to data from eight centers participating in the Americas Minimally Invasive Liver Resection (AMILES) registry. In comparison, the IWATE scoring system did not correlate with operative outcomes or postoperative complication rate in these patients. This may reflect differences in populations in the East and West, the authors said. The IWATE system was developed and revised in Japan where resection for hepatocellular carcinoma is common. The United States, however, has higher rates of resection for colorectal liver metastases, said study co-author Yasmin Essaji, MD, a fellow in hepatobiliary surgery at Virginia Mason Medical Center, in Seattle. The study is based on a retrospective analysis of 1,051 patients in the AMILES registry who underwent a minimally invasive hepatic resection. Patients were scored based on the Halls/Southampton and IWATE scoring systems. The Halls/Southampton score, which was developed in the United Kingdom, categorizes patients in groupings ranging from low, moderate to high. Analysis showed these groupings correlated with estimated blood loss (343, 499 and 681 mL; P<0.001); operative time (116, 225 and 265 minutes; P<0.001) and length of stay (3.53, 6.30 and 7.05 days; P<0.05), respectively. However, there was no statistically significant difference in need for conversion to open and postoperative complication rate. Analysis revealed no significant correlation with IWATE scores and operative or clinical outcomes. Investigators said more research will be needed using a prospective database to better delineate the predictive potential for these scoring systems. But difficulty scoring systems will help surgeons as they develop their skills, Dr. Essaji said. “It really helps to judge the difficulty of minimally invasive liver surgery and resections, and can help surgeons better identify cases where they feel comfortable so that they can start on the lower-difficulty procedures,” she said. Several surgical scoring systems have been proposed, but none are routinely used in practice. A third scoring system developed in France— the Institut Mutualiste Montsouris classification, or IMM—is not as widely validated or accepted as the IWATE and Halls/Southampton scoring systems, and was excluded from this study. The investigators did not differentiate between laparoscopic and robotic-assisted surgery in this analysis, but plan to assess those differences as more centers, especially those with robotic expertise, join the AMILES ■ registry.
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