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PubMed2001

[Minimally invasive surgery (MIC) in the area of the colon and rectum: technique of minimally invasive colorectal surgery].

Minimally invasive surgery is gaining increased importance in colorectal surgery. Since 1993 we have performed 378 minimally invasive colorectal procedures (appendzcetomy excluded): right-sided (n = 70) and left-sided (n = 160) hemicolectomy, anterior rectal resections (n = 72), and colostomy (n = 12), Hartmann procedure (n = 17), take-down operation (n = 25), rectopexy (n = 21) and coloproctomucosectomy (n = 2). The indications were diverticulitis (n = 147), benign tumor (n = 40), malignant tumor (n = 135), rectal prolapse (n = 21), Crohn's disease (n = 8), intestinal diversion (n = 25), colonic perforation (n = 2). Postoperative complications were observed in 21% of cases; anastomotic leak developed in 4%; mortality was 0.5%. In keeping with the current literature our data show that in the majority of cases surgical therapy of colorectal disease can be performed in minimally invasive fashion.

Colonic Diseases↗

PubMed1984

Tinidazole prophylaxis in elective colorectal surgery.

Bowel wall concentrations of tinidazole in two patient groups undergoing elective colorectal surgery were determined 8 h (22 patients) and 12 h (26 patients) after a single 500-mg intravenous infusion. In addition, the efficacy of 1-day tinidazole prophylaxis with 8- and 12-h dosage intervals in the prevention of postoperative infection complications was evaluated. The mean bowel wall tinidazole concentrations 8 and 12 h after infusion were 5.1 +/- 2.5 micrograms/g and 4.3 +/- 1.8 micrograms/g, respectively, which are considerably higher than the minimal inhibitory concentration for Bacteroides fragilis strains. Three patients out of 48 (6.3%) developed a wound infection: 1 from the 8-h dosage interval group (4.5%) and 2 from the 12-h interval group (7.7%). Wound cultures revealed only aerobic growth. The results confirm that an adequate bowel wall concentration remains for more than 12 h after a single 500-mg intravenous infusion of tinidazole. One-day tinidazole prophylaxis is an effective means of preventing postoperative infections after colorectal surgery.

Adult↗

PubMed2006

Mechanical bowel preparation for colorectal surgery.

BACKGROUND: Nosocomial infections are the most frequent complications of surgical patients. Most surgical site infections (SSI) are acquired intraoperatively and arise from the flora of the patient's skin, gastrointestinal tract, or mucous membranes. Although preoperative mechanical cleansing of the bowel is considered by many surgeons a cornerstone of modern elective colorectal surgery and, in association with antibiotic prophylaxis, a fundamental component of an intestinal antisepsis program, many surgeons do not perform preoperative mechanical preparation routinely. METHODS: Review of the pertinent literature. RESULTS: Some recent randomized trials and a Cochrane review found no proof that mechanical bowel preparation reduces the risk of complications after elective colorectal surgery. Indeed, there is some evidence that this intervention is associated with a higher rate of anastomotic leakage and wound complications. CONCLUSIONS: The dogma that mechanical bowel preparation is necessary before elective colorectal surgery may need to be reconsidered. On the other hand, such preparation decreases operating time by improving bowel handling during construction of the anastomosis. Moreover, it is helpful when intestinal palpation will be necessary for identification of a lesion.

Antibiotic Prophylaxis↗

PubMed2006

Operative time is a poor surrogate for the learning curve in laparoscopic colorectal surgery.

BACKGROUND: Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative time were less important than complication and readmission rates in defining good outcomes and hence the learning curve. METHODS: A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers. RESULTS: A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons). CONCLUSIONS: In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons' willingness to attempt more difficult cases rather than an accurate representation of a "learning curve." Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.

Adult↗

PubMed1996

The risk of thromboembolism in patients undergoing colorectal surgery.

Patients undergoing colorectal surgical procedures are at a moderately high risk for the development of thromboembolic events. Possible reasons may be that the procedures tend to be long in duration, patients are often placed in the lithotomy position, a pelvic dissection may be performed, and the indication is often inflammatory bowel disease or cancer. While prophylaxis with low dose heparin is effective at reducing this risk, approximately 10% of patients may still develop a thromboembolic event. Results on the effectiveness of low molecular weight heparin in this cohort of patients are pending.

Anticoagulants↗

PubMedDate not supplied

Implementation of a clinical pathway for laparoscopic colorectal surgery.

The purpose of this study was to assess through questionnaire the validity of our original clinical pathway for laparoscopic colorectal surgery. From 2001 to 2002, laparoscopic colorectal surgery was performed in 52 patients in our institution. All patients were out of bed within 3 days after the operation. The average postoperative hospital stay was 10.9 days. The implementation rate of the clinical pathway was 100%. As to the results of the questionnaire, 92.4% of the patients felt they could be discharged within 7 days after the operation, whereas >95% of the patients wanted to go home on a Sunday/holiday or the day before. All but 2 patients (96.2%) were satisfied with our therapy. In a clinical pathway for laparoscopic colorectomy, a high implementation rate and patients' satisfaction can be achieved by taking into account the patients' viewpoints; however, better patient education is necessary to shorten postoperative stay.

Colectomy↗

PubMed1984

[Perioperative antibiotic prophylaxis (single or multiple dose) in elective colorectal surgery. A randomized study].

In a randomized trial in 60 patients undergoing elective colorectal surgery the efficiency of intravenous antibiotic short time prophylaxis was determined. We compared single dose application with multiple dose prophylaxis for 24 h. The substance used was cefotaxime. The rate of wound infections was comparable in both groups (16.6 vs. 13.3%) as well as postoperative infections of the urinary tract (33.3 vs. 23.3%). The results of the study suggest that single dose prophylaxis is as efficient as multiple dose application to reduce postoperative infections in elective colorectal surgery.

Aged↗

PubMed2003

Oncological quality and preliminary long-term results in laparoscopic colorectal surgery.

BACKGROUND: Our aim here was interpret data on the perioperative course, oncological quality, and preliminary long-term results of laparoscopic colorectal surgery carried out with a curative intent. METHODS: The data were collected within the framework of a prospective multicenter observational study that has been ongoing since 1 Aug 1995 and includes 46 hospitals. Of a total of 3133 patients, 826 (26.4%) underwent a curative resection for colorectal carcinoma. RESULTS: The average age of the patients was 67.9 years; the sex distribution was almost 1:1. UICC staging of tumors (stages I, II, and III) showed the following figures: 301/36.4%, 265/32.1%, and 260/31.5%. In the majority of cases, an oncologically radical resection with high transection of the supplying vessels was performed. Intraoperative seeding of tumor cells was reported in 1.8% of the patients. In eight cases, the seeding was due to spontaneous rupture of the tumor. A mean of 13.5 lymph nodes in the resected specimen were investigated histopathologically (10.9 lymph nodes in stage I, 15 each in stages II and III). Depending on the individual hospital, we found a remarkable variation in the number of lymph nodes investigated. With a mean follow-up period of 2.1 years, Kaplan-Meier survival function showed acceptable results, both for rectal and colonic carcinoma, in comparison with conventional colorectal surgery. A stage-related consideration of the survival data yielded similar results. CONCLUSION: All in all, the results show that a laparoscopic colorectal procedure can meet oncological radicality criteria, even though certain reservations-in particular, in the case of procedures done with a curative intent-have not been completely eliminated.

Aged↗

PubMedDate not supplied

Low-dose, single-shot perioperative antibiotic prophylaxis in colorectal surgery.

Reductions of frequency of administration and dosage of antibiotic agents used in colorectal surgery may lower costs and the occurrence of adverse side effects. In a prospective randomized trial we evaluated two single-short regimens, a low dose of 1 g cefotiam against a standard dose of 2 g cefotiam, both in combination with 500 mg metronidazole. The low-dose group had twice the number of patients with wound sepsis (4 of 30) than the group receiving the standard antibiotic regimen (2 of 30). Two hours after infusion, the antibiotic concentrations in samples of serum, subcutaneous fatty tissue, and colonic wall of those patients receiving 1 g cefotiam were < 1 mg/l. The concentrations after administration of 2 g cefotiam were higher, as expected, and without any adverse side effects. In conclusion, we prefer infection prophylaxis by the standard dose of 2 g cefotiam plus 500 mg metronidazole in colorectal surgery.

Aged↗

PubMed1992

Prospective, randomized trial of inpatient vs. outpatient bowel preparation for elective colorectal surgery.

A prospective, randomized trial of inpatient vs. outpatient bowel preparation for elective colorectal surgery was performed in 100 consecutive patients. Bowel preparation was standardized for both groups and consisted of 4 liters of Colyte (Reed & Carnrick, Piscataway, NJ) and oral neomycin and Flagyl (G. D. Searle & Co., Skokie, IL) the day before surgery. Patients were randomized into four subcategories: ileocolostomy, colocolostomy, abdominal perineal resection, and other. Tap water enemas were administered on the morning of surgery to ensure and adequate mechanical preparation. Ninety-six percent of the inpatient group and 97 percent of the outpatient group were able to drink three-fourths or more of the oral lavage preparation (P = 0.789, Fisher's exact text). A mean of 2.26 tap water enemas was required to achieve clear returns for the inpatient group, compared with 2.28 tap water enemas for the outpatient group (P = 0.221, Fisher's exact test). The adequacy of the bowel preparation as graded by the primary surgeon was good (84 percent), fair (12 percent), and poor (4 percent) in the outpatient group (P = 0.673, Fisher's exact test). Wound infection developed in 4 percent of the inpatient group and 4 percent of the outpatient group (P = 1.0, Fisher's exact test). Anastomotic leak of intra-abdominal abscess was seen in one patient in each group (P = 1.0, Fisher's exact test). We conclude that outpatient bowel preparation is as effective as inpatient bowel preparation for elective colorectal surgery and offers the advantage of cost savings and shorter hospitalization.

Adult↗

PubMed1998

Platelet activation and serotonin release during colorectal surgery.

In vitro studies show serotonin has a profound vasospastic effect on human mesenteric arteries. A similar response has been shown in vivo in atherosclerotic primates. If platelet serotonin stores are released as a consequence of platelet activation during colorectal surgery, a similar effect may significantly alter the perfusion of newly formed anastomoses leading to ischaemia and anastomotic breakdown. Here we have studied the effects of surgery and anaesthesia on intraplatelet and plasma serotonin levels during the peri- and postoperative period following colorectal surgery. A series of six consecutive patients undergoing colorectal resection and anastomosis were selected. Peripheral venous blood samples, taken at specified times before and after surgery and prepared in a platelet stabilizing buffer solution, were analysed using a validated enzyme immunoassay technique. Intraplatelet serotonin levels were seen to fall post-operatively, whilst plasma serotonin levels were shown to rise, implying significant platelet activation and serotonin during the peri-operative period. This study demonstrates the increased bioavailability of serotonin during the peri-operative period in colorectal surgery patients. If the in vitro effects of this amine are mirrored in vivo, increased plasma levels of serotonin may have an important role in anastomotic dehiscence secondary to ischaemia.

Journal Article↗

PubMed2002

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery.

PURPOSE: The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients. METHODS: The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed. RESULTS: From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive. CONCLUSIONS: The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

Abdominal Muscles↗

PubMed2005

Prognosis after anastomotic leakage in colorectal surgery.

INTRODUCTION: Anastomotic leakage is a major complication of colorectal surgery causing a significant increase in 30-day mortality. The long-term prognosis of anastomotic leakage is poorly documented. This study was designed to assess whether anastomotic leakage affects five-year survival and local recurrence. METHODS: A total of 5,173 patients were recruited to the Wessex Colorectal Cancer Audit during the period September 1991 to August 1995 (prospective data, 5-year follow-up). The effect of anastomotic leakage on five-year survival and local recurrence was analyzed using Kaplan-Meier curves and the log-rank test. RESULTS: A total of 1,834 patients underwent a curative resection with an anastomosis (anastomotic leak = 71; 3.9 percent): 30-day mortality: 18.3 percent in the leak group, and 3.5 percent in the nonleak group (P < 0.001); local recurrence: 19 percent in the leak group, and 9.8 percent in the nonleak group (P = 0.018). A total of 1,201 patients underwent colonic anastomosis (anastomotic leak = 31; 2.6 percent). There was no significant difference in local recurrence or five-year survival between the leak and nonleak groups. A total of 633 patients underwent rectal anastomosis (anastomotic leakage = 40; 6.3 percent): 30-day mortality: 10 percent in the leak group, and 2 percent in the nonleak group (P = 0.014); cumulative five-year estimate of local recurrence: 25.1 (95 percent confidence interval, 9.6-40.5) percent in the leak group, and 10.4 (95 percent confidence interval, 7.7-13) percent in the nonleak group (P = 0.007). Cumulative five-year estimate of overall survival: 52.8 (95 percent confidence interval, 36.1-69.4) percent in the leak group, and 63.9 (95 percent confidence interval, 59.9-67.9) percent in the nonleak group (P = 0.19). CONCLUSIONS: After rectal anastomosis, an anastomotic leak is associated with a significant increase in local recurrence.

Aged↗

PubMed1992

A randomized prospective study to compare cefotetan with cefuroxime plus metronidazole as prophylaxis in elective colorectal surgery.

This study compares the efficacy of cefotetan with the combination of cefuroxime plus metronidazole as antibiotic prophylaxis in elective colorectal surgery when given over the first 24 h postoperatively. There was no significant difference in wound infection rates between the two groups (14.7% for cefotetan and 13.9% for cefuroxime plus metronidazole), or the rates of other infective complications. Adverse reactions occurred with equal frequency in both treatment groups and no serious side effects occurred. Cefotetan is a safe and effective antibiotic for use as prophylaxis in elective colorectal surgery. Its advantages are that it is a single agent with a spectrum covering both aerobic Gram-negative rods and anaerobic organisms and, because of its long half-life, needs only to be given at 12-hourly intervals.

Cefotetan↗

PubMed2003

Comparison of robotically performed and traditional laparoscopic colorectal surgery.

INTRODUCTION: Robotic laparoscopic surgery is postulated to result in better surgical results by allowing improved instrument manipulation and three-dimensional vision. The authors' experience performing robot-assisted laparoscopic colorectal surgery is reported. METHOD: Standard laparoscopic procedures with robot-assisted laparoscopic colon mobilization and vascular ligation were performed. Data relating to the operative procedure, hospital stay, and direct costs were collected. Results were compared with age, gender, and procedure case-matched controls taken from a prospective laparoscopic colorectal surgery database. RESULTS: Six robot-assisted laparoscopic surgeries (2 right hemicolectomies, 3 sigmoid colectomies, and 1 Wells rectopexy) were performed between December 2001 and June 2002. There was no associated morbidity. Operative time was increased from a median time of 108 minutes for standard laparoscopic colorectal surgery to 165 minutes for robot-assisted laparoscopic surgeries (P = 0.0313; Wilcoxon matched-pairs signed-rank test for nonparametric data). This was primarily a result of the time required for robot set-up. Blood loss, length of stay, and hospital cost were not significantly different between groups. Additional direct equipment costs for RAC cases included robotic laparoscopic instruments and sterile drapes (approximately US $350 per case), without including acquisition and maintenance costs for the robot. CONCLUSION: Robot-assisted laparoscopic colectomy is a feasible and safe procedure. Although three-dimensional vision and dexterity are facilitated, operative time is increased and the overall additional expense of robotics is of concern. Robot-assisted laparoscopic colectomy requires further evaluation to establish clinical and financial benefits before introduction to routine practice. Such techniques may, in the future, facilitate complex laparoscopic techniques.

Aged↗

PubMed2003

Trends in preparation for colorectal surgery: survey of the members of the American Society of Colon and Rectal Surgeons.

The utility of antibiotic and mechanical preparation for colorectal surgery is controversial, and numerous different regimens are used. The aim of this study was to detect trends in preparation for surgery among American colon and rectal surgeons. Members of the American Society of Colon and Rectal Surgeons practicing in the United States were surveyed with a postal questionnaire regarding their routine preparations for colon and rectal surgery. Five hundred fifteen (40%) of the 1295 questionnaires sent were returned. Eighty-one per cent of the respondents had completed an accredited colorectal training program, and the average experience in practice was 13.7 (+/- 8.7) years. Half of the surgeons felt that prophylactic oral antibiotic is essential, 41 per cent felt it was doubtful, and 10 per cent considered oral prophylaxis unnecessary. Despite these statements 75 per cent of the surgeons routinely utilized oral antibiotics (96% of them used a combination of two drugs), 11 per cent used them selectively, and only 13 per cent omitted oral prophylaxis from their practice. Similarly although the usefulness of intravenous antibiotics was questioned by 11 per cent of the surgeons 98 per cent routinely used them. The average number of postoperative doses was two (+/- 1.9). Although 10 per cent of the surgeons questioned the importance of mechanical preparation more than 99 per cent routinely used it. Forty-seven per cent of the surgeons used sodium phosphate, 32 per cent used polyethylene glycol, and 14 per cent alternated between these two options. We conclude that although the use of oral antibiotic prophylaxis for colorectal surgery is controversial among surgeons it is still routinely practiced by 75 per cent. Intravenous antibiotic prophylaxis and mechanical cleansing, however, are still a dogma and almost invariably used. There is a trend toward the use of a shorter course of postoperative intravenous antibiotics and the use of sodium phosphate for mechanical cleansing.

Administration, Oral↗

PubMed1983

Undernutrition in elective colorectal surgery. Implications for post operative morbidity.

The nutritional status of 65 patients undergoing elective colorectal surgery was assessed using 5 conventional nutritional indices, percentage ideal weight, mid arm muscle circumference, triceps skin fold thickness, serum albumin and serum total iron binding capacity. Only 9 patients had values for all five indices which are taken to represent normal nutritional status. This survey suggests that many patients undergoing elective colorectal surgery in this country have subnormal values of the indices commonly used for nutritional assessment but only severe depression of serum albumin however appears to adversely affect the outcome of surgery.

Journal Article↗

PubMed1997

Mechanical bowel preparation for elective colorectal surgery. A prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions.

AIM: The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery. METHODS: All eligible patients were prospectively randomized to receive either 4 l of standard polyethylene glycol (PEG) solution or 90 ml of sodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxon's rank-sum test and Fisher's exact test. RESULTS: Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaP solutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P < 0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17 vs. 32 percent; P < 0.0002), less abdominal pain (12 vs. 22 percent; P = 0.004), less bloating (7 vs. 28 percent), and less fatigue (8 vs. 17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P < 0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P < 0.0001). For quality of cleansing, surgeons scored NaP as "excellent" or "good" in 87 compared with 76 percent after PEG (P = not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P = not significant). CONCLUSION: Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Colonic Diseases↗