Is the NICE procedure the great equalizer for patients with high BMI undergoing resection for diverticulitis?

Background: By 2030, projections indicate that nearly half of USS adults will be obese, with 29 states exceeding a 50% obesity rate. High Body Mass Index (BMI) presents particular challenges in treating diverticulitis, including worsened symptoms and increased risk of surgical complications. The Robotic Natural orifice Intracorporeal Anastomosis with Transrectal Extraction (NICE) procedure has been developed for colorectal surgeries to tackle these challenges.

The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis.

Introduction: We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018.

Methods: A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique.

Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases.

Introduction: We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients.

Background: The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.

Methods: Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated.

A national evaluation of the predictors of compliance and survival from adjuvant chemotherapy in high-risk stage II colon cancer: A National Cancer Database (NCDB) analysis.

Background: Guidelines recommend adjuvant chemotherapy for stage II colon cancer with high-risk features, but there has been little study on compliance with guidelines. This work sought to evaluate compliance with adjuvant chemotherapy and factors associated with compliance in high-risk stage II colon cancer. This work's hypothesis was that compliance with adjuvant chemotherapy recommendations is low, but improves overall survival when used.

Robotic NICE Procedure Using Handsewn Technique.

Introduction: In 2018, we described a robotic natural orifice-assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the natural orifice intracorporeal anastomosis with transrectal extraction procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis. We present a technical video and initial experience depicting the unique steps to accomplish this procedure with colorectal end-to-end handsewn anastomosis.

Real-World Data on Liposomal Bupivacaine and Inpatient Hospital Costs After Colorectal Surgery.

Introduction: This study compared costs of care among colorectal surgery patients who received liposomal bupivacaine versus those who did not (control) from a health institution perspective.

Material And Methods: This pharmacoeconomic evaluation was conducted among adults undergoing open or minimally invasive colorectal resection at an academic medical center from May 2016 to February 2018. Healthcare resource utilization was derived from the electronic health record.

Colorectal cancer in the 45-to-50 age group in the United States: a National Cancer Database (NCDB) analysis.

Background: Amid increasing awareness of early-onset colorectal cancer (CRC), guidelines in the United States (US) recently lowered the recommended routine CRC screening age from 50 to 45 in average-risk individuals. There are little data on the number of patients in this age group diagnosed with CRC prior to these changes. Our objective was to audit the historic CRC case trends and impact of CRC in the 45-to-50-year-old category prior to new screening recommendations.

A national evaluation of the use and survival impact of adjuvant chemotherapy in Stage II colon cancer from the national cancer database.

Aim: Stage II colon cancers are a heterogeneous category, with controversy over use of adjuvant chemotherapy (AC). Patients with high-risk features may benefit from AC to improve overall survival (OS). Current guidelines do not routinely recommend AC in low-risk cases, but the actual use and benefit on OS in this cohort have not been fully examined on a national scale.

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis.

Background: Totally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort.

Opioid-Sparing Effect of Liposomal Bupivacaine and Intravenous Acetaminophen in Colorectal Surgery.

Background: This study evaluated the opioid-sparing effect of liposomal bupivacaine and intravenous acetaminophen in colorectal surgery.

Materials And Methods: This study was a retrospective, 2 × 2 factorial cohort conducted at an academic medical center from May 2016 to February 2018. Patients undergoing open or minimally invasive colorectal resection were included.

Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure.

Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures; however technical challenges have limited this approach following conventional laparoscopic surgery. The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided ICA, however, there are no reports involving more complex left-sided procedures such as diverticulitis. Furthermore, there are no reports of natural orifice-assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed transrectally, thereby completely eliminating the need for an abdominal wall incision other than for port sites.

Robotic left-sided colorectal resection with natural orifice IntraCorporeal anastomosis with extraction of specimen: The NICE procedure. A pilot study of consecutive cases.

Background: Despite numerous benefits, only a small fraction of laparoscopic left-sided colectomy is accomplished without the need for an abdominal incision to retrieve the specimen and prepare for anastomosis. We report our early experience with a robotic approach using Natural orifice IntraCorporeal anastomosis with Extraction of specimen (NICE) to help overcome the technical limitations and challenges of this approach.

Methods: Twenty consecutive patients presented for elective sigmoid or rectosigmoid resection for benign and malignant disease and underwent the NICE procedure.

Impact of long-acting local anesthesia on clinical and financial outcomes in laparoscopic colorectal surgery.

Background: Our objective was to assess clinical and financial outcomes with long-acting liposomal bupicavaine (LB) in laparoscopic colorectal surgery.

Methods: Patients that received local infiltration with LB were strictly matched to a control group, and compared for postoperative pain, opioid use, length of stay (LOS), hospital costs, and complication, readmission, and reoperation rates.

Results: A total of 70 patients were evaluated in each cohort.

Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach.

Background: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy.

A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits.

Background: The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery.

Methods: A Truven MarketScan claim-based analysis identified all 2013 elective, inpatient colectomies.

Is there value in alvimopan in minimally invasive colorectal surgery?

Background: Alvimopan's goal is to minimize postoperative ileus and optimize outcomes; however, evidence in laparoscopic surgery is lacking. Our goal was to evaluate the benefit of alvimopan in laparoscopic colorectal surgery with an enhanced recovery pathway (ERP).

Methods: Laparoscopic colorectal cases were stratified into alvimopan and control cohorts, then case-matched for comparability.

Transversus abdominis plane blocks: pilot of feasibility and the learning curve.

Background: Our goal was to evaluate the learning curve for transversus abdominis plane (TAP) block placement and identify issues that impede successful placement.

Methods: Three novices were prospectively evaluated performing ultrasound-guided TAP blocks in 10 consecutive patients. Operators were assessed on medication knowledge, setup/placement, procedural steps, and performance time.

Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients.

Background: Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series.

Study Design: A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014.

Does one score fit all? Measuring risk in ulcerative colitis.

Background: The American College of Surgeons Surgical Risk Calculator was developed to improve risk stratification and surgical quality but has not been studied at the institutional level for specific disease states, like ulcerative colitis (UC).

Methods: UC patients undergoing colorectal resection had predicted risk calculator data compared with actual outcomes for length of stay (LOS), complications, reoperation, and death. Main outcome measures were the difference in actual vs predicted outcomes.

Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned.

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges.