Larson, David W.

BACKGROUND: Emergency colorectal surgery traditionally uses open approaches, with limited minimally invasive adoption. Although robotic surgery demonstrates benefits in elective procedures, its role in emergency settings remains unclear. This retrospective study evaluated outcomes of robotic vs laparoscopic and open approaches in emergency colorectal procedures and predicted future adoption trends. STUDY DESIGN: We analyzed 83,483 patients from the American College of Surgeons NSQIP database (2012 to 2021) who underwent emergency colorectal surgery: 53,731 open, 26,649 laparoscopic, and 3,103 robotic procedures. Outcomes were analyzed using multivariable regression, propensity score matching, and g-computation analysis. Classification and Regression Trees were used to analyze surgical approaches to selection factors, whereas vector autoregressive models projected future usage trends. RESULTS: Robotic surgery demonstrated significantly lower conversion rates to open surgery compared with laparoscopy (7.8% vs 24.2%; adjusted odds ratio 0.32, 95% CI 0.28 to 0.36), shorter length of stay (incidence rate ratio 0.67, 95% CI 0.65 to 0.69), and fewer surgical complications (odds ratio 0.65, 95% CI 0.60 to 0.72). Robotic usage increased from 0% to 6.6% (2012 to 2021), with trends suggesting substantial growth toward 20.2% by 2025. Patient selection favored robotics for stable patients with diverticulitis (68.4%) and cancer without sepsis, whereas open surgery remained predominant in patients with perforation, severe sepsis, or significant comorbidities. CONCLUSIONS: In selected emergency colorectal procedures, robotic surgery demonstrates superior outcomes vs conventional approaches. These outcomes may be partially influenced by patient selection factors because robotic cases involved more clinically stable patients. These findings support expanded robotic platform availability for emergency procedures, although careful patient selection remains essential. The projected increase in robotic usage reflects a growing acceptance of this technology, suggesting that its technical advantages can extend to more complex emergency cases than previously considered.

Objective: To determine if a Super Learner (SL) machine learning approach could improve the predictive accuracy of the American College of Surgeons Risk Calculator (ACS-RC) for postoperative complications in patients undergoing colorectal surgery. Summary of Background Data: Machine learning (ML) has shown significant potential to advance medical fields, including surgical risk prediction. Current tools, like the ACS-RC which uses logistic regression and extreme gradient boosting, are standard but may be enhanced by more advanced ML ensembles. Methods: This retrospective study analyzed colorectal surgery cases from the 2018-2022 ACS National Surgical Quality Improvement Program (NSQIP) database. An SL model, which combines multiple ML algorithms, was developed to predict fourteen postoperative outcomes. Its performance was compared against traditional logistic regression (LOG) and extreme gradient boosting (XGB) models. Key performance metrics included discrimination (AUROC, AUPRC) and calibration (Brier score, Hosmer-Lemeshow test). Results: The SL model demonstrated superior performance across all predicted complications when compared to both LOG and XGB. It showed superior discrimination for severe outcomes, achieving an AUROC greater than 0.94 for predicting mortality. The SL model was also more accurate in predicting infectious complications and length of stay, and its calibration metrics indicated a better overall fit and accuracy. Conclusions: The Super Learner model enhances the accuracy of postoperative risk prediction in colorectal surgery. Its superior performance suggests it is a promising tool for improving personalized patient counseling, aiding clinical decision-making, and optimizing resource allocation.

Lay Summary Oral vancomycin shows promise in treating pouchitis in patients with primary sclerosing cholangitis and ulcerative colitis. In this study, vancomycin helped reduce stool frequency, urgency, and incontinence. More research is needed to confirm its long-term benefits and best treatment practices.

Background and Objectives: Perineal wound complications and pelvic fluid collections or abscesses following proctectomy for Crohn’s disease are a common cause of morbidity and might be mitigated by filling the pelvis and occluding the pelvic inlet with a flap. Alternative flap options can be considered when inadequate omentum is available and when avoiding myofasciocutaneous flaps. Materials and Methods: A retrospective review of our Crohn’s proctectomy database was conducted to identify patients who underwent a non-omental or non-myofasciocutaneous local pedicle flap to their pelvis or pelvic exclusion using biological material during surgery. The techniques and outcomes of these alternative techniques are described in detail. Results: 228 patients underwent proctectomy for Crohn’s disease during the 10-year study period. However, only six patients had their pelvis filled or pelvic inlet occluded using a non-omental, non-myofasciocutaneous local pedicled flap or biological material. The techniques identified included two sigmoid mesocolic flaps, one peritoneal, preperitoneal fat and falciform ligament flap, one perivesical fat flap, one Gerota’s fat pad flap, and one bovine pericardial patch assisted pelvic exclusion. These flaps’ clinicopathological and operative characteristics, surgical outcomes, and technical aspects are described. Conclusions: When greater omentum is unavailable or inadequate and myofasciocutaneous flaps need to be avoided, local pedicled flaps using a range of intra-abdominal tissues or biological material can be used to fill the pelvis or occlude the pelvic inlet after proctectomy for Crohn’s disease. These techniques may help to prevent short and long-term complications associated with having a pelvic dead space.

Objective: To assess trends in surgical approaches (robotic, laparoscopic, and open) for various procedures, including prostatectomy, nephrectomy, cystectomy, colectomy, proctectomy, pancreatectomy, hepatectomy, and esophagectomy, and predict the future of these surgical approaches. Summary Background Data: The rapid adoption of robotic surgery has raised critical questions about the future of traditional laparoscopic techniques. Understanding the trends and potential dominance of robotic surgery is essential for surgical training, healthcare infrastructure, and resource allocation. Methods: This retrospective observational study utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2023. Vector Autoregressive modeling analyzed trends and predicted future patterns for robotic, laparoscopic, or open surgical approaches across the specified procedures. The study included all reported cases in the database where the surgical approach was specified. Results: The analysis revealed a continued shift towards robotic surgery, particularly dominant in urologic procedures and rapidly adopted for complex operations like hepatectomy and esophagectomy. Laparoscopy’s use is declining across most specialties, though it remains significant in colectomy. Open surgery persists at high rates, especially in pancreatic and rectal operations. Projections suggest robotic surgery will surpass laparoscopy in colectomy (44.5%) and proctectomy (38.3%) by 2026. Conclusions: The transition toward robotic surgery continues across specialties at varying rates. These findings have significant implications for surgical training, healthcare infrastructure, and resource allocation. The high rates of open surgery in certain procedures highlight opportunities for broader adoption of minimally invasive techniques.

Abstract Aim Growing evidence suggests that immune/inflammatory pathways play a crucial role in the persistence of symptoms in diverticular disease (DD). We hypothesize that chronic diverticulitis triggers a self‐sustained inflammatory status which can be detected by measuring the levels of tumor necrosis factor‐α (TNF‐α) and interleukin‐6 (IL‐6). The aim of this study was to investigate the systemic levels of TNF‐α and IL‐6 before and after elective surgery in patients with DD, and their relationship with the gastrointestinal quality of life index (GIQLI) score. Method This prospective multicentric study enrolled patients from the Diverticular Disease Registry (DDR‐Trial, NCT04907383). All adult patients diagnosed with symptomatic uncomplicated diverticular disease (SUDD), uncomplicated recurrent diverticulitis (URD) and smouldering diverticulitis (SmD) between 1st December 2022 and 31st December 2023 were included in this study. Exclusion criteria were as follows: no surgery, a concurrent chronic immunomodulated systemic disease, a SARS‐CoV‐2‐positive test in the previous 12 months, a history of cancer in the previous 5 years, patients treated with immunomodulators, an American Society of Anesthesiologists category of class IV, and complicated acute diverticulitis. Results Seventy‐two patients were included: 52 (72%) with URD, 11 (15%) with SUDD, and nine (13%) with SmD. The median postsurgery – presurgery (Δ)IL‐6 and ΔTNF‐α levels were −16.8 and −17.3 pg/mL, respectively ( p < 0.001 for both; Wilcoxon test). Spearman correlation revealed a significant, negative association between the ΔGIQLI and the ΔIL‐6, as well as the ΔTNF‐α ( p < 0.001 for both). Greater reduction in the levels of IL‐6 and TNF‐α following surgery are associated with higher GIQLI scores postoperatively. Conclusion Patients with chronic diverticulitis may experience persistent systemic inflammation driven by a colonic trigger. Surgical removal of this trigger appears to enhance GIQLI outcomes reducing IL‐6 and TNF‐α across surgery.

AbstractAimThe relationship between the number of stapler firings (SFs) during robotic rectal transection and the risk of colorectal/coloanal anastomotic leakage (AL) is controversial. This study investigates whether the number of robotic SFs is associated with an increased risk of AL.MethodRetrospective review of adult patients who underwent robotic total mesorectal excision (TME) and partial mesorectal excision (PME) with double‐stapled colorectal or coloanal anastomosis for both benign and malignant colorectal diseases between 2015 and 2023 across three enterprise‐wide hospitals. Primary outcome: the effect of multiple SFs on postoperative AL rate among patients who underwent one, two, or three or more SFs. Secondary outcome: the effects of other potential risk factors on postoperative AL.ResultsOf 503 patients who underwent robotic colorectal resection with a double‐stapled anastomosis, 56 (11%) developed a postoperative AL. The number of SFs was not associated with the AL rate (p = 0.51): the univariable and multivariate analyses found no correlation between the AL rate and the increasing number of SFs required, compared with one SF as the reference (adjusted two SFs, OR = 1.1, 95% CI: 0.6–2.2, p = 0.77 vs. adjusted three or more SFs, OR = 0.98, 95% CI: 0.4–2.3, p = 0.96). On multivariate analysis, AL was strongly associated with male gender (OR = 2.5, 95% CI: 1.3–4.9, p = 0.005) and with TME versus PME (OR = 2.8, 95% CI: 1.5–5.5, p = 0.002).ConclusionThe number of robotic SFs for rectal transection is not correlated with postoperative AL.

Background: Total mesorectal excision (TME) remains the gold standard for the resection of rectal cancer regardless of the modality: open, laparoscopic, or robotic. The transanal TME (TaTME) approach has been utilized to overcome the difficulties encountered with the dissection of tumors in the distal pelvis. Recently, a single-port robotic approach (rSPa) was introduced, where three arms and a camera emanate from a 2.5 cm diameter port. This report presents the first experience in the United States combining those two approaches (rSPa TaTME) in rectal cancer, evaluating its safety and oncologic outcomes. Methods: This is a retrospective review of our prospectively maintained rectal cancer database. Patient demographics, tumor characteristics, neoadjuvant treatment, and oncologic and surgical outcomes were recorded. Results: Between May 2022 and August 2024, ten patients (six females, four males) with a median age at surgery of 53 years (range: 38–85) and a mean BMI of 26 (±5) kg/m2 were included for analysis. The median distance of tumors from the anorectal junction was 3.2 cm (range: 2–5.3 cm). All patients had negative margins, with eight complete TME specimens, one near complete, and one incomplete. The mean number of lymph nodes harvested was 24 (±11). The average operative time was 351 (243–411) min. The average length of stay was four days. The ileostomy was reversed in nine out of ten patients. Six patients experienced complications within 30 days of surgery. There were no local or distal recurrences, with a mean follow-up of 20 months (range: 4–30). Conclusions: rSPa TaTME is a unique and innovative method of combining two minimally advanced approaches for the resection of distal rectal cancers, with acceptable surgical and oncologic outcomes.

Importance Tumor deposits have prognostic value in colon cancer, but the current American Joint Committee on Cancer (AJCC) staging only considers them if there are no concurrent positive lymph nodes. Objective To devise a staging system for colon cancer by integrating counts of tumor deposits with positive lymph nodes while retaining the current AJCC staging framework. Design, Setting, and Participants This retrospective cohort study examines data from a large-volume, tertiary care center database (January 2010 through March 2023 with follow-up until December 2023) and the population-based National Cancer Database (January 2010 through December 2020 with follow-up until December 2021). Participants were adults (age 18-75 years) with stage III colon adenocarcinoma who underwent chemotherapy, and had a specified positive lymph node count and tumor deposit count were selected. Exposure A real positive lymph nodes count was developed and used to derive Sassun-Mayo N/tumor, lymph node, and metastasis (TNM) stages that were compared with the AJCC N/TNM stages. Main Outcomes and Measures Receiver operating characteristic (ROC) curves and Kaplan-Meier analyses for 3-year overall survival were performed to assess the efficiency of the 2 staging systems. The concordance index was used for validation using the National Cancer Database. Results From a total patient number of 11 162 (institutional) and 848 704 (national), the final patient numbers were 788 and 77 790, respectively. The institutional database patients had a mean (SD) age of 58.5 (11.5) years; there were 433 male patients (54.9%) and 355 female (45.1%). The national database patients had a mean (SD) age of 59.3 (10.6) years; there were 40 315 male patients (51.8%) and 37 475 female (48.2%). ROC curve areas were improved using the Sassun-Mayo stages (3-year death for AJCC TMN, 0.63 [95% CI, 0.57-0.69] vs 0.66 [95% CI, for 0.60-0.72] for Sassun-Mayo TNM). Kaplan-Meier curves revealed visible overlaps among AJCC N stages, which were absent in the Sassun-Mayo N stages. The concordance index in the Sassun-Mayo N/TNM stages was 0.611 and 0.616, respectively, while in the AJCC N/TNM stages, it was 0.598 and 0.606, respectively. Patients upstaged from N1 to N2 (n = 10 307; 13.2%) had a 3-year overall survival rate nearly identical to that of AJCC N2a patients. Additionally, 3001 patients (3.9%) were upstaged from N2a to N2b, indicating that 13 308 patients (17.1%) with stage III colon cancer across cohorts were understaged. Conclusions and Relevance This study found that Sassun-Mayo N/TNM staging provided superior overall survival stratification compared with the current AJCC staging, suggesting that their implementation could improve prognostication in colon cancer.