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PubMed1993

Laparoscopic colectomy: a critical appraisal.

A multicenter retrospective study was undertaken to assess the efficacy and safety of laparoscopy in colon and rectal surgery. To minimize potential bias in interpretation of the results, all data were registered with an independent observer, who did not participate in any of the surgical procedures. Sixty-six patients underwent a laparoscopic procedure. Operations performed included sigmoid colectomy (19), right hemicolectomy (15), low anterior resection (6), colectomy with ileal pouch-anal anastomosis (IPAA) (5), and abdominoperineal resection (APR) (3). The conversion rate from laparoscopic colectomy to celiotomy was 41 percent. Major morbidity and mortality were 24 percent and 0 percent, respectively. Length of stay, hospital costs, and lymph node harvest were compared between the sigmoid resection and right hemicolectomy subgroups. Data from traditional sigmoid colectomies and right hemicolectomies were obtained from the same institutions for comparison. Mean postoperative stay for laparoscopically completed sigmoid and right colectomies was significantly less than that for either the converted or the traditional groups (P < 0.02). Total hospital cost for traditional right hemicolectomy was significantly less than that for the converted group (P < 0.05) but not the laparoscopic group. Laparoscopic sigmoid resection showed no significant total hospital cost difference among traditional, converted, and laparoscopic groups. Lymph node harvest in resections for carcinoma was comparable in all groups. These preliminary data suggest that laparoscopic colon and rectal surgery can be accomplished with acceptable morbidity and mortality when performed by trained surgeons. Length of stay is shorter, but there is no proven total hospital cost benefit. Appropriate registries will be necessary to adequately assess long-term outcome.

Adolescent↗

PubMed1996

Interleukin-6 and stress hormone responses after uncomplicated gasless laparoscopic-assisted and open sigmoid colectomy.

PURPOSE: Laparoscopic colectomy has increasingly been advocated as an option for treatment of colonic disease. The purpose of this study was to compare effects of laparoscopic-assisted sigmoid colectomy (LAS) and conventional open colectomy (OPEN) on postoperative cytokine and stress hormone responses. METHODS: Fourteen patients with sigmoid colon cancer, apparently free of preoperative complications, were analyzed. Patients in both groups underwent sigmoid colectomy with lymphadenectomy. LAS was performed by the gasless abdominal wall-lifting method. A 5 cm incision was placed at the beginning of the operation. Blood samples were taken preoperatively and postoperatively for measurement of interleukin-6, glucagon and C-reactive protein. Urinary catecholamine excretions were also determined postoperatively. RESULTS: The two groups of patients were similar with respect to age (61 +/- 7 for LAS vs. 64 +/- 9 for OPEN) and sex. Intraoperative blood loss did not differ significantly between groups (112 +/- 97 ml for LAS vs. 366 +/- 380 ml for OPEN). Operative times for LAS tended to be longer than those for OPEN (231 +/- 67 vs. 169 +/- 45 minutes; P = 0.08). Similar time courses of postoperative interleukin-6, C-reactive protein, and stress hormone responses were observed in both groups. No significant differences were observed in the magnitude of changes except that the serum interleukin-6 level on day of surgery (postoperative day 0) was significantly higher in LAS patients than in those receiving OPEN. In addition, interleukin-6 levels showed a significant positive correlation with operative duration (r = 0.582; P < 0.05). CONCLUSIONS: Data suggest that stress responses after sigmoid colectomy, in patients undergoing LAS, are comparable with those of patients receiving OPEN and that the early interleukin-6 response after surgery appears to be associated with operative time.

Aged↗

PubMed1994

Emergency subtotal/total colectomy with anastomosis for acutely obstructed carcinoma of the left colon.

PURPOSE: The operation of choice for acutely obstructed carcinoma of the left colon is controversial. The aim of the study was to evaluate the results of its management by emergency subtotal/total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 44 patients (mean age, 72.4 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 6.8 percent. Two patients over 90 years of age died postoperatively as a result of cardiopulmonary complications. An 83-year-old female died as a result of an anastomotic dehiscence. Morbidity was 6.8 percent including one fistula which recovered without surgery. There were three synchronous colon cancers. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serosal tears on the cecum, ensures restoration of gut contiguity via a "safe" ileocolonic anastomosis, and removes occasional lesions proximal to the index cancer. It is a safe procedure given that operative mortality rates are as low as with elective surgery.

Acute Disease↗

PubMed1996

Quality of life after prophylactic colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis.

BACKGROUND: Prophylactic colectomy or proctocolectomy is standard treatment for colorectal manifestation of familial adenomatous polyposis (FAP), a dominantly inherited disorder for which the risk of developing colorectal cancer in an untreated patient is close to 100 percent. Hereditary nonpolyposis colorectal cancer (HNPCC) is also dominantly inherited but has a lower risk of colorectal cancer than FAP and does not have a clinically obvious phenotype. The role of prophylactic colectomy in patients with HNPCC is controversial. PURPOSE: This study was performed to examine the outcome of colectomy and ileorectal anastomosis (IRA) so its use as a prophylactic procedure can be better evaluated. METHODS: Records of all patients undergoing IRA for FAP between 1985 and 1993 were reviewed. Demographic data and data about the operation were collected. Surgical outcome data included length of hospital stay, complications, bowel function, quality of life, and patient satisfaction. RESULTS: There were 51 patients with a median age of 28 years; 24 were male. All but eight patients were asymptomatic, and all had less than 1,000 polyps in the resected specimen. Mean surgery time was 3.5 hours, mean blood loss was 406 ml, and median length of hospital stay was seven days. There were no deaths, and eight patients (16 percent) had complications. Mean number of stools per day after median follow-up of 4.2 years was 3.6. Only 11 patients had nighttime stooling. Four patients reported seepage, 9 had some incontinence, and 16 had urgency. Quality of life, rated on a scale of 0 to 10, was 7 or above in 44 of 48 assessed patients. Quality of health was rated 7 or higher in all 48 patients, energy level was 7 or higher in 39 patients, and overall happiness with surgery was 7 or higher in 47 patients. CONCLUSIONS: Colectomy and IRA is a relatively safe operation that results in minimum disturbance of bowel function. Patient satisfaction is usually high. Prophylactic colectomy can be offered to HNPCC gene carriers with a greater understanding of the likely outcome of surgery.

Adenomatous Polyposis Coli↗

PubMed2001

Long-term follow-up of patients undergoing colectomy for colonic inertia.

PURPOSE: Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction. METHODS: Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year follow-up. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrheal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome as excellent, good, fair, or poor. RESULTS: Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted until the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency. CONCLUSION: This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.

Colectomy↗

PubMed2000

Risk factors for morbidity and mortality after colectomy for colon cancer.

PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, "do not resuscitate" status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

Adult↗

PubMed2006

Total colectomy improves altered distribution of regulatory T cells in patients with ulcerative colitis.

BACKGROUND: It is now generally believed that regulatory T cells (Tregs) play an important role in peripheral tolerance, and a defect in Tregs is considered one of the most important factors in the induction of various kinds of autoimmune disease including ulcerative colitis (UC). Here, we examined the change in frequency of Tregs phenotype in five patients with UC whose condition had not been controllable by conventional conservative therapy and who were scheduled for total colectomy. AIMS: The aim of this study was to elucidate the role of Tregs in the pathogenesis of UC in a clinical setting. METHODS: Peripheral blood mononuclear cells (PBMCs) were obtained from five patients with UC, and the change in frequency of Tregs was analyzed by flow cytometry before total colectomy and on postoperative days 1, 7, and 20. Tregs were defined as CD4+ CD25+ CD45RA+ T cells, and data (%) were expressed as frequency of Tregs/CD4+ T cells. Peripheral blood mononuclear cells (PBMCs) from healthy blood donors (n = 5) and from patients undergoing other types of major surgery (n = 5) were used as controls. RESULTS: Comparison with normal subjects showed that generation of Tregs was suppressed in UC patients before they underwent total colectomy (0.95 versus 5.06; P = 0.009). The frequency of Tregs increased shortly after total colectomy. The frequency at postoperative days 1, 7, and 20 was 3.81%, 8.13%, and 3.76%, respectively. There were significant differences in the change in frequency in the period before surgery and postoperative day 1, between postoperative days 1 and 7, and between days 7 and 20. CONCLUSIONS: Elimination of targeted antigens residing in the colorectal mucosa by total colectomy improved the suppressed distribution of Tregs in UC patients. The present study provides the first direct clinical evidence that Tregs play a pivotal role in the pathogenesis of UC.

Adult↗

PubMed2000

Fate of the rectum and ileal recurrence rates after total colectomy for Crohn's disease.

The aim of this study was to examine the fate of the rectum and ileal recurrence rates after total colectomy for Crohn's disease. One hundred thirty patients who underwent total colectomy between 1970 and 1997 were reviewed; 65 patients underwent end ileostomy with an oversewn rectal stump (TC+I) and 65 had ileorectal anastomosis (IRA). Patients treated by TC+I had significantly more rectal involvement (93%) than those having IRA (43%) (p < 0.0001). The incidence of ileal disease at the time of colectomy was similar (TC+I 34% versus IRA 32%; p = 0.99). Rectal recurrence requiring proctectomy was significantly more common after TC+I (51%) than after IRA (26%) (p = 0.01), whereas ileal recurrence requiring resection was significantly more common after IRA (45%) than after TC+I (18%) (p = 0.002). Using Kaplan-Meier methods, the 10-year cumulative probability of proctectomy was significantly higher after TC+I than IRA (58% versus 22%; p = 0.0001), whereas the 10-year cumulative probability of ileal resection was significantly higher after IRA than TC+I (37% versus 18%; p = 0.03). In conclusion, the proctectomy rate is higher after colectomy and ileostomy probably due to a higher incidence of preoperative rectal involvement. By contrast, the ileal recurrence rate is higher after colectomy and IRA.

Adolescent↗

PubMed2005

Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma.

PURPOSE: The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of the study was to evaluate the results of its management by emergency subtotal or total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 72 patients (mean age 74.9 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability, and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 9.7% (7 patients). An 83-year-old woman died as a result of an anastomotic dehiscence; the six other deaths resulted of cardiopulmonary complications. Postoperative morbidity was 15% (11 patients) including two fistulas, which recovered without surgery. There were eight synchronous colon carcinomas. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one-stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serous tears on the cecum. It ensures restoration of gut contiguity via a "safe" ileocolonic anastomosis and removes occasional lesions proximal to the index cancer.

Acute Disease↗

PubMed2000

Effects of colectomy on bile composition, cholesterol saturation and cholesterol crystal formation in humans.

Total or subtotal colectomy is the surgical treatment of choice for patients with ulcerative colitis. Recently it has been reported that colectomy may lead to increased lithogenicity of bile, short nucleation time, cholesterol crystal formation, and gallstone disease. We examined whether colectomy in patients with ulcerative colitis leads to changes in bile composition that predisposes to cholesterol crystal formation and cholesterol gallstone disease. Ten consecutive patients who had previously undergone ileostomy and colectomy because of ulcerative colitis were admitted for ileal pouch surgery. At operation bile was obtained by puncture of the gallbladder. Controls were 35 patients undergoing cholecystectomy (23 for cholesterol gallstone disease and 12 for reasons other than gallstone disease). The gallbladder bile was analyzed for cholesterol crystals, bile acid, and biliary lipid composition, cholesterol saturation, and nucleation time. The colectomized patients had normal biliary lipid composition, normal cholesterol saturation, and normal nucleation time, in contrast to gallstone patients who displayed highly supersaturated bile with a short nucleation time. Thus patients with ileostomy after colectomy because of ulcerative colitis have normal cholesterol saturation and nucleation time of bile.

Adolescent↗

PubMed2002

Subtotal colectomy with primary ileorectostomy is effective for unlocalized, diverticular hemorrhage.

BACKGROUND: A large proportion of patients with acute colonic diverticular bleeding undergo emergency surgery without successful prior localization of the bleeding site. This study sought to determine the surgical techniques of choice for unlocalized, diverticular hemorrhage. METHODS: We reviewed the data on 42 consecutive patients (median age 76 years, range 44-91) with acute colonic diverticular bleeding operated on between November 1993 and December 2000. Mean follow-up was 4.1 years. RESULTS: Preoperative localization of the bleeding site was possible in six patients (14%), by colonoscopy in two and by angiography in four. Ten patients underwent segmental colectomy with primary anastomosis (5 "directed", 5 "blind") and 32 subtotal colectomy with primary ileorectostomy (1 "directed", 31 "blind"). Subtotal colectomy is the more extensive surgical procedure (longer resected bowel, greater blood loss), and although it was performed in older patients, there were no significant differences between segmental and subtotal colectomy with respect to operation time, morbidity, mortality, hospital stay, number of bowel movements, continence scores, rebleeding rate, or patient satisfaction. CONCLUSIONS: Subtotal colectomy with primary ileorectostomy for unlocalized colonic diverticular bleeding is a safe and effective surgical procedure providing complete bleeding control and preserving continence.

Adult↗

PubMed2004

Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients.

BACKGROUND: It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease. METHODS: All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience. RESULTS: A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred. CONCLUSION: Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

Adult↗

PubMed2002

Intraoperative endoscopy in laparoscopic colectomy.

BACKGROUND: The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy. METHODS: We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon. RESULTS: Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications. CONCLUSION: Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.

Aged↗

PubMed2003

Age and type of procedure influence the choice of patients for laparoscopic colectomy.

BACKGROUND: The aim of this retrospective, case-matched controlled study was to determine the benefit of laparoscopic-assisted colectomy (LC) for the elderly (>75 years of age) and the young (<75 years of age) compared to an open colectomy (OC) control group. METHODS: A retrospective review of 39 patients older than 75 years of age and 38 patients younger than 75 years of age who underwent LC for colorectal cancer between 1991 and 1999 was performed. LC patients were matched with an open control group for procedure, age, gender, year of procedure, and surgeon. Procedures included right and left colectomy, anterior resection of the rectosigmoid, and abdominoperineal resection. Measured intraoperative variables included anesthesia time, operative time, and estimated blood loss. Postoperative parameters consisted of duration of intravenous or epidural narcotic usage, return of bowel function (RBF), length of stay, and independence at discharge. These variables were compared in the entire group of 154 patients. RESULTS: Mean ages were 81.4 and 81.8 years for LC and OC age >75 and 62.9 and 62.7 for LC and OC age <75. Mean anesthesia time and operative time were significantly longer (p < 0.05) for LC compared to OC (46.8 vs 39.3 and 159.3 vs 111.7 min, respectively) for age >75 and for age <75 (47.1 vs 40.3 and 182.8 vs 135.5 min, respectively). LC achieved faster recovery in both age groups: RBF (3.9 vs 4.9 days for age >75; 6.7 vs 7.7 days for age <75) (p < 0.05). Narcotic usage was shorter for the LC group age <75 (3.3 vs 4.4 days; p < 0.05). There was no significant difference in independence at discharge between LC and OC in either age group. Faster recovery was seen with left LC in age >75 and right LC in age <75 compared to OC. CONCLUSION: The advantages of LC over OC are the same for the elderly and the young. There may be a selective benefit of laparoscopic left colectomy in the elderly and laparoscopic right colectomy in the young.

Age Factors↗

PubMed2004

Comparative study of electrothermal bipolar vessel sealer and ultrasonic coagulating shears in laparoscopic colectomy.

BACKGROUND: As an alternative to suture ligatures of the vessels, an electrothermal bipolar vessel sealer (EBVS) was recently developed. Meanwhile, ultrasonic coagulating shears (UCS) have been widely used clinically to provide hemostatic cutting in laparoscopic procedures. We conducted a comparative study to investigate the relative advantages of these two instruments. METHODS: The study included 30 patients with colon cancer who underwent laparoscopic colectomy using either the EBVS or the UCS. We performed a comparative analysis of the instruments by viewing videotapes showing their application in laparoscopic transverse colectomy and sigmoidectomy. RESULTS: Average patient age was 71.6 +/- 1.4 years. Average hospital stay was 14.2 +/- 1.0 days. There were no statistical differences between the groups in age and hospital stay. The incidence of rebleeding was significantly lower in the EBVS group than in the UCS group for both surgical procedures (0.3 vs 1.2 in transverse colectomy, 0.3 vs 2.0 in sigmoidectomy, respectively). In addition, the required time for mesocolon dissection was also significantly shorter when the EBVS was used in both laparoscopic transverse colectomy and sigmoidectomy (7.9 vs 18.4, 15.0 vs 27.6, respectively). CONCLUSION: The use of the EBVS will enable surgeons to reduce the total operating time for laparoscopic colectomy.

Aged, 80 and over↗

PubMed2005

Vascular pedicle ligation techniques during laparoscopic colectomy. A prospective randomized trial.

BACKGROUND: A variety of devices are available for pedicle ligation during laparoscopic colectomy including vascular staplers, clips, and electrothermal bipolar vessel-sealing devices. This study assesses their speed, reliability, and cost to guide surgeons in their choice for intracorporeal pedicle ligation. METHODS: A prospective randomized study comparing laparoscopic vascular staplers and disposable clip appliers (S/C) with the LigaSure Atlas (LIG) was performed during elective right, left, and total colectomy. Cases were stratified by procedure. Failure was defined as any bleeding after proper pedicle ligation. RESULTS: The study included 48 S/C patients and 52 LIG patients with no differences in demographics, diagnosis, procedure, number of vessels ligated per procedure, or operative time. Failure occurred for 14 (9.2%) of the 152 vessels ligated in the S/C group, as compared with 5 (3%) of the 169 vessels ligated in the LIG group (p = 0.02). The median blood loss associated with device failure was 50 ml (range, 20-50 ml) in S/C group, as compared with 100 ml (range 25-800 ml) in the LIG group (p = 0.054). Major blood loss attributable to device failure and surgeon error occurred in only one LIG case. The mean cost per case of vessel ligation was significantly less in the LIG group (317 dollars +/- 0 dollars vs 400 dollars +/- 112 dollars; p < 0.001). The cost differences were greatest for total colectomy (LIG = 317 dollars +/- 0 dollars vs S/C = 565 dollars +/- 67 dollars; p = 0.002). CONCLUSION: Device failure, although more common in the S/C group, does not result in significant blood loss. The LigaSure Atlas is more cost effective during laparoscopic colectomy, especially total colectomy, and may allow the surgeon more versatility in its application.

Adult↗

PubMed2006

Laparoscopic total colectomy for colorectal cancers: a comparative study.

BACKGROUND: No previous report could be found in the literature comparing laparoscopic and open total colectomy for colorectal cancers, especially synchronous colorectal cancers. This study aimed to compare the short-term clinical outcomes and oncologic results of laparoscopic and open total colectomy or proctocolectomy for colorectal cancers. METHODS: Between July 1997 and January 2005, six patients with colorectal cancers underwent elective laparoscopic total colectomy or proctocolectomy at the authors' institution. Clinical data for 12 patients who underwent elective open total colectomy or proctocolectomy for colorectal cancers during the same period were prospectively collected and compared. RESULTS: The median follow-up periods were 43.9 months for the laparoscopic group and 48.2 months for the open group. Conversion to open procedure was required for one patient (16.7%) in the laparoscopic group because of bleeding. The median operative time was significantly longer in the laparoscopic group (427.5 min; range, 280-480 min vs 172.5 min; range, 90-260 min; p = 0.001). The patients in the laparoscopic group required a significantly shorter duration of parenteral analgesia (3 vs 5 days; p = 0.01), but there were no differences in time to first bowel motion, time to resumption of diet, time to full ambulation, and duration of hospital stay between the two groups. Perioperative morbidity rates were comparable between the two groups, and there was no operative mortality. The oncologic results, including number of lymph nodes removed, recurrence rates, and survival rates, were similar in the two groups. CONCLUSIONS: Laparoscopic total colectomy has short-term clinical outcomes (postoperative recovery and perioperative morbidity and mortality rates) and oncologic results similar to those of open surgery for treating patients with colorectal cancers. Our study has shown that the only advantage of laparoscopic over open surgery is a shorter duration of analgesic requirement, but at the expense of a longer operative time.

Aged↗

PubMed2006

Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection.

BACKGROUND: Large colonic polyps or polyps that lie in anatomical locations that are difficult to access at endoscopy may not be suitable for endoscopic resection and therefore may require partial colectomy. This approach eradicates the polyp and allows an oncologic resection should the polyp prove to be malignant. The purpose of this study was to assess outcomes of a laparoscopic approach for the management of these polyps. METHODS: Patients referred for laparoscopic colectomy for colonic polyps were identified from the prospective colorectal laparoscopic surgery database. Demographics, operative details, and final pathology were reviewed. RESULTS: Fifty-one consecutive patients (27 male) with a mean age of 68 +/- 11.4 years, ASA classification (1/2/3/4) of 0/21/27/3, and body mass index (BMI) of 26.5 +/- 4.9 were identified. Right (RHC) and left (LHC) colectomy was performed for 39 right and 12 left colonic polyps. Mean operating time (OT) was 87 +/- 30 min (81 for RHC, 105 for LHC) and mean hospital stay was 3.1 +/- 1.9 days. There were six complications (17.7%), including anastomotic leak (n = 1), small bowel obstruction (n = 2), abscess (n = 1), and exacerbation of preexisting medical conditions (n = 2). Four patients were readmitted (7.8%); one required CT scan-guided abscess drainage (1.9%) and two required reoperation (3.9%). Five patients (9.8%) were converted because of adhesions (n = 3), obesity (n = 1), and inability to identify the area that was tattooed at colonoscopy (n = 1). Mean polyp size was 3.1 cm, and pathology revealed tubular (n = 14), tubulovillous (n = 33) and villous adenoma (n = 2), pseudopolyp (n = 1), and prolapse of the appendix into the cecum mimicking an adenoma (n = 1). High-grade dysplasia was seen in four tubular (33%) and five tubulovillous adenomas (15.5%). Adenocarcinoma not identified at colonoscopy was found in 11 polyps (20%), 9 tubulovillous (27.8%) and both villous adenomas (100%). CONCLUSIONS: Large colonic polyps unresectable at colonoscopy are associated with a high rate of unsuspected cancer. This requires a formal colectomy rather than transcolonic polypectomy. Laparoscopic colectomy offers safe and effective management of these polyps with the benefits of accelerated postoperative recovery.

Abscess↗