Background Duration of surgery is a main cost factor of surgical training. The purpose of this analysis of operative times for laparoscopic cholecystectomies (LC) was to quantify the extra time and related costs in regards to the surgeons' experience in the operating room (OR). Methods All LC performed between January 01, 2005 and December 31, 2008 in 46 hospitals reporting to the database of the Swiss Association for Quality Management in Surgery (AQC) were analyzed (n = 10,010). Four levels of seniority were specified: resident (R), junior consultant (JC), senior consultant (SC), and attending surgeon (AS). The differences in operative time according to seniority were investigated in a multivariable log-linear and median regression analysis controlling for possible confounders. The OR costs were calculated by using a full cost rate in a teaching hospital. Results A total of 9,208 LC were available for analysis; 802 had to be excluded due to missing data (n = 212) or secondary major operations (n = 590). Twenty-eight percent of the LC were performed by R as teaching operations (n = 2,591). Compared with R, the multivariable analysis of operative time showed a median difference of -2.5 min (-9.0; 4.8) for JC and -18 min (-25; -11) for SC and -28 min (-35; -10) for AS, respectively. The OR minute costs were €17.57, resulting in incremental costs of €492 (159; 615) per operation in case of tutorial assistance. Conclusions The proportion of LC performed as tutorial assistance for R remains low. Surgical training in the OR causes relevant case-related extra time and therefore costs.

IMPORTANCE National guidelines on interval resection for prevention of recurrence after complicated diverticulitis are inconsistent. Although US and German guidelines favor interval colonic resection to prevent a perceived high risk of recurrence, UK guidelines do not.OBJECTIVES To investigate patient management and outcomes after an index inpatient episode of nonoperatively managed complicated diverticulitis in Switzerland and Scotland and determine whether interval resection was associated with the rate of disease-specific emergency surgery or death in either country. DESIGN, SETTING, AND PARTICIPANTSThis secondary analysis of anonymized complete national inpatient data sets included all patients with an inpatient episode of successfully nonoperatively managed complicated diverticulitis in Switzerland and Scotland from January 1, 2005, to December 31, 2015. The 2 countries have contrasting health care systems: Switzerland is insurance funded, while Scotland is state funded. Statistical analysis was conducted from February 1, 2018, to October 17, 2019. MAIN OUTCOMES AND MEASURESThe primary end point defined a priori before the analysis was adverse outcome, defined as any disease-specific emergency surgical intervention or inpatient death after the initial successful nonsurgical inpatient management of an episode of complicated diverticulitis, including complications from interval elective surgery. RESULTSThe study cohort comprised 13 861 inpatients in Switzerland (6967 women) and 5129 inpatients in Scotland (2804 women) with an index episode of complicated acute diverticulitis managed nonoperatively. The primary end point was observed in 698 Swiss patients (5.0%) and 255 Scottish patients (5.0%) (odds ratio, 0.98; 95% CI, 0.81-1.19). Elective interval colonic resection was undertaken in 3280 Swiss patients (23.7%; median follow-up, 53 months [interquartile range, 24-90 months]) and 231 Scottish patients (4.5%; median follow-up, 57 months [interquartile range, 27-91 months]). Death after urgent readmission for recurrent diverticulitis occurred in 104 patients (0.8%) in Switzerland and 65 patients (1.3%) in Scotland. None of the investigated confounders had a significant association with the outcome apart from comorbidity.CONCLUSIONS AND RELEVANCE This study found no difference in the rate of adverse outcome (emergency surgery and/or inpatient death) despite a 5-fold difference in interval resection rates.

Aim Crohn's disease (CD)‐related rectovaginal fistulas (RVFs) are rare, challenging to treat and associated with a high morbidity. Due to a significant lack of data, we aimed to analyse the safety and feasibility of allogeneic adipose‐derived stem cells (ASCs) in the treatment of CD‐related RVF. Method Four consecutive patients with CD‐related RVF underwent treatment with expanded allogeneic ASCs extracted from a healthy donor in a tertiary referral centre in 2019. None of the patients had an intestinal diversion at the time of the treatment. Follow‐up was performed 6 months postoperatively. Results The median operation time was 45 min with a median hospital stay of 3 days. No intra‐operative complications occurred. Three patients (75%) developed recurrent RVF after a median follow‐up of 19 days. Two patients required surgical treatment including loose seton drainage due to discharge and pain. One patient developed recurrence of symptoms after 10 days, but refused further surgical therapy. Only one patient (25%) showed healing of the RVF, with re‐epithelialization of both the vaginal and rectal opening and absence of clinical symptoms. Conclusion Expanded allogeneic ASC therapy represents a novel safe treatment option for CD‐associated RVF. Although efficacy appears limited, further controlled studies are required to draw robust conclusions.

The probability of colon resection for patients hospitalized with acute uncomplicated diverticulitis increased between periods while the overall number of colon resections declined. A change of practice expected given the paradigm shift towards conservative treatment could not be confirmed in this analysis.

MC cause relevant intraoperative delay and increased costs. Step-by-step protocols for a laparoscopic cholecystectomy may lead to a reduction in MC and should be further evaluated.

HRSL is effective in reducing delays due to MC in a teaching institution with limited team experience. These findings should be tested in larger potentially cluster-randomized controlled trials. The trial has been registered with clinicaltrials.gov: NCT03329859.

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