Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial

Postoperative peritoneal dissemination of ovarian cancer cells is not promoted by carbon-dioxide pneumoperitoneum at low intraperitoneal pressure in a syngenic mouse laparoscopic model with controlled respiratory support: a pilot study

STUDY OBJECTIVE

To investigate postoperative peritoneal dissemination of ovarian cancer cells in a syngenic mouse model with and without controlled respiratory support (CRS).

DESIGN

Randomized controlled trial (Canadian Task Force classification I).

SETTING

Academic facility.

SUBJECTS

Sixty-four female C57BJ6 mice.

INTERVENTIONS

Mice were randomly divided into 4 surgical groups: anesthesia alone group; 2 carbon-dioxide pneumoperitoneum groups, 1 with low (2 mm Hg) and 1 with high (8 mm Hg) intraperitoneal pressure (IPP); and finally the laparotomy group. Each of the 4 groups was then subdivided into one group with CRS and the other without. Mouse ovarian cancer cells were injected intraperitoneally just before surgery.

MEASUREMENTS AND MAIN RESULTS

A laparotomy was performed to evaluate postoperative peritoneal dissemination of ovarian cancer cells on postoperative day 14. A computerized analysis system was then used to evaluate peritoneal dissemination. In the groups with CRS, the peritoneal dissemination score was significantly higher in the laparotomy and high IPP groups compared with anesthesia alone (p <.0001 vs laparotomy, p <.002 vs high IPP) and low IPP (p <.0002 vs laparotomy, p <.004 vs high IPP) groups. No significant difference was detected between the low IPP and anesthesia alone groups.

CONCLUSION

Postoperative peritoneal dissemination of ovarian cancer cells is not promoted by a carbon-dioxide pneumoperitoneum with a low IPP in a mouse model with CRS when assessed on postoperative day 14.

Feasibility of laparoscopic techniques as the surgical approach of choice for primary colorectal cancer: an analysis of 570 consecutive cases

BACKGROUND

Since the Clinical Outcomes of Surgical Therapy (COST) trial data were reported in May 2004, the laparoscopic technique for primary colorectal cancer has been increasingly used and become the approach of choice at our center. This study aimed to evaluate our laparoscopic experience of 570 consecutive patients between October 2000 and December 2006, and assess the feasibility of this technique as the surgical approach of choice for primary colorectal cancer.

METHODS

The study times were divided into three periods based on the COST trial report and the time when the laparoscopic technique was accepted as the surgical approach of choice at our center (period I: October 2000 to May 2004, II: June 2004 to December 2005, III: January to December 2006). Data regarding clinicopathological, surgical, and perioperative outcomes were collated from registry and compared between periods.

RESULTS

The use of laparoscopic surgery increased from 2.4% in period I, to 19.2% in period II, to 66.1% in period III. Over the periods, the proportion of rectal cancer and right colon cancer increased (p < 0.001), T- and N-stage became more advanced (p < 0.001, p = 0.011 respectively), and operative time decreased (p < 0.001). The overall open conversion and morbidity rates were 3.5% and 9.8%, respectively, and these did not differ between periods.

CONCLUSION

It was possible to apply laparoscopic approach in two-thirds of primary colorectal cancer patients. The short-term favorable outcomes support the feasibility of laparoscopic technique as surgical approach of choice for colon cancer. Laparoscopic resection for rectal cancer may require a randomized clinical trial prior to gain similar acceptance.

Benefits of laparoscopic colorectal resection are more pronounced in elderly patients

PURPOSE

The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome in elderly patients.

METHODS

A series of 535 patients with colorectal disease who had been randomly assigned to laparoscopic (n=268) or open (n=267) resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4 percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge.

RESULTS

Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic and open groups (P=0.0001). In the open group, elderly patients had higher morbidity rate (37.5 vs. 23.9 percent; P=0.02) and longer length of hospital stay (13 vs. 10.6; P=0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2 vs. 15.1 percent) and length of hospital stay (9.5 vs. 9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2 vs. 37.5 percent; P=0.01) and length of hospital stay (9.5 vs. 13; P=0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate (15.1 vs. 23.9 percent; P=0.06) and length of stay (9.1 vs. 10.6; P=0.004) were less pronounced.

CONCLUSIONS

Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery.

Conversion of laparoscopic colon resection does not affect survival in colon cancer

BACKGROUND

Laparoscopic and open resections of colon cancer are considered oncologically equivalent treatment methods. Conversion of laparoscopic procedures, however, was associated with decreased survival in colon cancer patients in the only prior study examining this question. We conducted this study to evaluate the effect of conversion on survival.

METHODS

A series of consecutive patients treated with laparoscopic resection of colorectal cancer (n = 174) in the period 1998-2003 was evaluated retrospectively. Median follow-up was 51 months with a minimum of 3 years.

RESULTS

There was no statistically significant difference in all-cause mortality between laparoscopically completed and converted groups (22/143, 15.4% versus 8/31, 25.8%; OR 1.9, p = 0.164). Kaplan-Meier survival analysis did not show any survival difference between the two groups (p = 0.266).

CONCLUSIONS

The results of our study suggest there is no survival difference in patients requiring conversion of laparoscopic resection indicated for colorectal cancer. Further examination of this question is warranted to determine whether laparoscopic resection of colorectal cancer should be offered to all patients, including those at high risk for conversion.

Laparoscopic bowel resection in the setting of metastatic colorectal cancer

BACKGROUND

This study aimed to review the outcomes of laparoscopic colorectal resection for patients with stage IV colorectal cancer.

METHODS

From the prospectively collected database for patients who underwent surgery for colorectal cancer in our institution, those with stage IV colorectal cancer who underwent elective resection of tumor during the period from January 2000 to June 2006 were included. The outcomes of those with laparoscopic resection were reviewed and comparison was made between patients with laparoscopic and open resection.

RESULTS

A total of 200 patients (127 men) with median age of 69 years (range: 25-91 years) were included, and 77 underwent laparoscopic resection. Conversion was required in ten patients (13.0%) and all except one conversion were due to fixed or bulky tumors. There was no operative mortality in the laparoscopic group. The complication rate was 14% and the median postoperative hospital stay was 7 days. When patients with laparoscopic resection were compared with those with open operations, there was no difference in age, gender, comorbidity, or tumor size between the two groups. However, the complication rate was significantly lower in those with laparoscopic resection (14% versus 32%, P = 0.007) and the median hospital stay was significantly shorter (7 days versus 8 days, P = 0.005). The operative mortalities and the survivals were similar in the two groups.

CONCLUSIONS

Colorectal resection can be performed safely in patients with stage IV colorectal cancer. The operative outcomes in terms of complication rate and hospital stay compare favorably with patients with open resection.

A 6-year review of surgical morbidity and oncological outcome after high anterior resection for colorectal malignancy with and without splenic flexure mobilization

OBJECTIVE

High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved.

METHOD

From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed.

RESULTS

A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity (P = 0.1926), 30-day mortality (P =0.3285), lymph node harvest (P = 0.2127) or survival (P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization (P < 0.0001).

CONCLUSION

No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found.

Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery

PURPOSE

Although laparoscopic colorectal surgery may permit early recovery and discharge from hospital, short lengths of stay are not routinely achieved. This is partly because accelerated recovery programs with early discharge are associated with high readmission and complication rates, especially after open colorectal surgery.

METHODS

This study was designed to examine safety and outcomes after laparoscopic colectomy in cases discharged within 72 hours of surgery. A total of 118 consecutive patients (mean age 60 years) underwent elective laparoscopic colectomy by a single surgeon. An accelerated recovery program included an overnight intravenous patient- controlled analgesia pump, diet and oral analgesia on postoperative Day 1, and standardized discharge criteria.

RESULTS

Mean body mass index was 28.5 (range, 20-45), and mean operative time was 142 minutes with no mortality. Median stay was 3 days, and 20 percent had a complication within 30 days. Eighty-two patients (70 percent) were discharged within 72 hours of surgery (10 Day 1; 46 Day 2; 26 Day 3). Patients were grouped and analyzed by day of discharge. Discharge on Days 1 to 2 was associated with significantly lower complication rates than seen for the overall group. Although patients discharged on Days 1 to 2 had the lowest readmission rate, this did not reach statistical significance.

CONCLUSIONS

Readmission and complication rates are low in patients discharged on Days 1, 2, or 3 after laparoscopic colectomy when using standardized postoperative care protocols and standardized discharge criteria.

Nationwide trends in laparoscopic colectomy from 2000 to 2004

BACKGROUND

Over the past 5 years, several studies have demonstrated that laparoscopic colon resection is an acceptable and perhaps preferable alternative to open resection for both benign diseases and cancer. The extent to which laparoscopic colon resections are used nationally is not known.

METHODS

The Nationwide Inpatient Sample was used to identify laparoscopic and open elective colon resections performed in the United States each year from 2000 through 2004. The trends in adoption of the laparoscopic technique for each type of colon resection and for the most common diagnoses were identified, and differences in patient and provider characteristics were examined.

RESULTS

From 2000 to 2004, the proportion of colon resections performed laparoscopically increased from 3% to 6.5%. The proportion performed for cancer increased from 1.4% to 4.3%, and for benign disease from 4.6% to 8.2%. Patients treated laparoscopically tended to be younger (median age, 61 years vs 66 years; p < 0.001) and to have fewer comorbidities (Charlson score of zero for 58.1% vs 37%; p < 0.001). Laparoscopic colon resections were more widely adopted in teaching versus nonteaching hospitals (5.1% vs 3.7%; p < 0.001) and in urban versus rural hospitals (4.7% vs 2.2%; p < 0.001).

CONCLUSION

Although the proportion of colon resections performed laparoscopically increased in the first half of this decade, it has remained very low. This trend is similar across procedure types and diagnoses. It remains to be seen whether greater patient demand and more recent trials will result in wider adoption of the laparoscopic approach.

Open right colectomy is still effective compared to laparoscopy: results of a randomized trial

OBJECTIVE

The primary goal of this study was to clarify whether a laparoscopic (LPS) approach could be considered the dominant strategy in patients undergoing right colectomy.

SUMMARY BACKGROUND DATA

Because few nonrandomized or small sized studies have been carried out so far, definitive conclusions about the role of LPS right colectomy cannot be drawn.

METHODS

Two hundred twenty-six patients, candidates for right colectomy, were randomly assigned to LPS (n = 113) or open (n = 113) resection. The postoperative care protocol was the same for both groups. Trained members of the surgical staff who were not involved in the study registered postoperative morbidity. Follow-up was carried out for 30 days after hospital discharge. The following costs were calculated: surgical instruments, operative room occupation, routine care, postoperative morbidity, and hospitalization.

RESULTS

Conversion rate in the LPS group was 2.6% (3 of 113). Operative time (in minutes) was longer in the LPS group (131 vs. 112, P = 0.01). Postoperative morbidity rate was 18.6% in the open group and 13.3% in the LPS group (P = 0.31). Postoperative stay was one day longer in the open group (P = 0.002). No difference was found in postoperative quality of life. The additional operative charge in the LPS group was euro980 per patient randomized (euro821 for surgical instruments and euro159 for longer operative time). The savings in the LPS group was euro390 per patient randomized (euro144 for shorter length of hospital stay and euro246 for the lower cost of postoperative morbidity). The net balance resulted in a euro590 extra charge per patient randomly allocated to the LPS group.

CONCLUSION

LPS slightly improved postoperative recovery. This translated into a savings that covered only 40% of the extra operative charge. Therefore, open right colectomy could be still considered an effective procedure.

Oncologic outcomes of laparoscopic surgery for rectal cancer: a systematic review and meta-analysis of the literature

AIM

To review and compare the oncologic outcomes in patients with rectal cancer undergoing laparoscopic vs. open rectal surgery.

METHODS

An electronic literature search was performed for trials reporting oncologic outcomes for laparoscopic rectal resections. Variables of interest were survival, recurrence rates, margin status and nodal retrieval. Trials were excluded if variables were not specifically analysed for rectal resections. A meta-analysis was performed to assess the difference in oncologic outcomes between the two treatment approaches.

RESULTS

Data on a total of 1403 laparoscopic (LG) and 1755 open (OG) rectal resections were gathered from 24 publications. Overall survival at 3 years (LG=76%, OG=69%) was not statistically different between the two treatment groups. The mean local recurrence rates were 7% for laparoscopic and 8% for open procedures (NS). There was no difference in radial margin positivity, 5% of patients undergoing laparoscopic surgery compared to 8% for open surgery. Laparoscopic procedures harvested a mean of 10 nodes as compared to 12 for open procedures, p=0.001.

CONCLUSIONS

Data gathered in this meta-analysis indicate that there are no oncologic differences between laparoscopic and open resections for treatment of primary rectal cancer.

Colon and rectal cancer: laparoscopic or open?

Early experiences with laparoscopic colectomy were unfavorable, with higher than expected rates of wound tumor implants and concerns about short and long-term compromised oncologic outcomes. Several international randomized controlled trials were initiated to address concerns regarding compromised oncologic outcomes. Each of the trials was designed to test the hypothesis that level 1 evidence supports the general feasibility and recovery advantage as well as cancer equivalence of laparoscopic colectomy in curable colon cancer. The following four phase III randomized controlled trials have completed accrual and reported early data on recovery benefits for laparoscopic colectomy: Barcelona, Clinical Outcomes of Surgical Therapy Study Group (COSTSG), Colon Cancer Laparoscopic or Open Resection (COLOR), and Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC). These trials have uniformly and consistently shown a significant reduction in the use of narcotics and oral analgesics and length of hospital stay, as well as a faster return of diet and bowel function, with laparoscopic colectomy. Two of the trials, Barcelona and COSTSG, have sufficient maturation and follow-up to report recurrence and survival data, and neither has found a survival disadvantage in patients treated with laparoscopic colectomy. Results of the Barcelona trial suggest a cancer-related survival advantage in patients treated with laparoscopic colectomy, based solely on differences in patients with stage III disease; this is not confirmed by the COSTSG trial. Results of the CLASICC and COLOR trials, as well as 5-year data from the COSTSG trial, should definitively address survival results. The investigational experience with laparoscopic rectal cancer is not as mature; the subset of rectal cancer patients (n = 253) in the CLASICC trial provides the only available randomized controlled trial data. Laparoscopic colectomy in patients with curable cancer is accepted as an alternative to open colectomy, whereas the viability of laparoscopic rectal cancer resection requires further investigation.

Economic evaluation of laparoscopic surgery for colorectal cancer

OBJECTIVES

The aim of this study was to assess the cost-effectiveness of laparoscopic surgery compared with open surgery for the treatment of colorectal cancer.

METHODS

A Markov model was developed to model cost-effectiveness over 25 years. Data on the clinical effectiveness of laparoscopic and open surgery for colorectal cancer were obtained from a systematic review of the literature. Data on costs came from a systematic review of economic evaluations and from published sources. The outcomes of the model were presented as the incremental cost per life-year gained and using cost-effectiveness acceptability curves to illustrate the likelihood that a treatment was cost-effective at various threshold values for society's willingness to pay for an additional life-year.

RESULTS

Laparoscopic surgery was on average pounds 300 more costly and slightly less effective than open surgery and had a 30 percent chance of being cost-effective if society is willing to pay pounds 30,000 for a life-year. One interpretation of the available data suggests equal survival and disease-free survival. Making this assumption, laparoscopic surgery had a greater chance of being considered cost-effective. Presenting the results as incremental cost per quality-adjusted life-year (QALY) made no difference to the results, as utility data were poor. Evidence suggests short-term benefits after laparoscopic repair. This benefit would have to be at least 0.01 of a QALY for laparoscopic surgery to be considered cost-effective.

CONCLUSIONS

Laparoscopic surgery is likely to be associated with short-term quality of life benefits, similar long-term outcomes, and an additional pounds 300 per patient. A judgment is required as to whether the short-term benefits are worth this extra cost.

Laparoscopic versus open colorectal resection for cancer: a meta-analysis of results of randomized controlled trials on recurrence

AIMS

Laparoscopic resection for colorectal cancer remains controversial. This is because it is uncertain whether recurrence rates after laparoscopic-assisted surgery is comparable to those reported after open surgery. We performed a meta-analysis of the published literature in an attempt to answer this question.

METHODS

Eligible articles were identified by searches of MEDLINE, EMBase and the Cochrane database. Prospective randomized clinical trials were eligible if they included patients with colorectal cancer treated by laparoscopic surgery versus open surgery and followed for recurrence.

RESULTS

Ten trials with information on disease recurrence on 2474 patients were included. In the combined results, no statistically significant difference in the OR for overall recurrence between the laparoscopic surgery and open surgery group was found (OR 0.93, 95% CI 0.71-1.21, P=0.58). Stratified by recurrence type, the combined results of the individual reports show no statistically significant difference for local recurrence (OR 0.80, 95% CI 0.50-1.29, P=0.36), distant metastases (OR 0.90, 95% CI 0.62-1.29, P=0.56) and port or wound-site recurrence (OR 1.04, 95% CI 0.18-6.03, P=0.97) between the two surgical techniques.

CONCLUSION

This meta-analysis supports that the recurrence rates for patients with colorectal cancer treated by laparoscopic surgery do not differ from those for open surgery. Longer follow-up studies will further define outcomes, comparing the two techniques in the treatment of colorectal cancer.

Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial

OBJECTIVE

Laparoscopic colectomy has been proved to be both technically and oncologically feasible. However, the approach has been criticized for its procedural complexity and long operative time as a result of the loss of tactile feedback and absence of depth perception. The advent of hand-access devices offered a potential solution to these problems. This randomized controlled trial aims to compare hand-assisted laparoscopic colectomy (HALC) with open colectomy (OC) in the management of right-sided colonic cancer.

METHODS

Adult patients with nonmetastatic carcinoma of cancer or ascending colon were recruited. Patients were excluded if they presented with surgical emergencies, had synchronous tumors on work-up, or when the tumor was larger than 6.5 cm in any dimension or preoperative imaging. Recruited patients were randomized to undergo either HALC or OC by the same surgical team. Outcome measures included operative time, blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications, as well as disease recurrence and patient survival.

RESULTS

Eighty-one patients (HALC = 41, OC = 40) were successfully recruited. The 2 groups were matched for age, gender distribution, body mass index, and comorbidities. No significant difference was observed between the 2 groups in the distribution of tumors and the final histopathological staging. HALC took significantly longer than OC (110 min vs. 97.5 minutes, P = 0.003) but resulted in significantly less blood loss (35 mL vs. 50 mL, P = 0.005). Patients after HALC experienced significantly less pain, required significantly less parenteral and enteral analgesia, recovered faster, and was associated with a shorter length of stay (7 days vs. 9 days, P = 0.004). With median follow-up of 28 to 30 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83% vs. 74%, P = 0.90).

CONCLUSION

HALC retained the same short-term benefits of the pure laparoscopic approach. The technique is associated with a slightly increased but acceptable operative time. Aside as a useful adjunct in complex laparoscopic procedures, the hand-assisted laparoscopic technique is also a useful, if not more effective, alternative for patients with right-sided colonic cancer.

Economics and the laparoscopic surgery learning curve: comparison with open surgery for rectosigmoid cancer

BACKGROUND

Wide-ranging costs of laparoscopic surgery (LAP) are associated with variations in the experience levels of surgeons. There is no available report on the changes of economic outcomes relative to the LAP learning curve in the treatment of colorectal cancer. In the present study, we have compared changes in economic outcomes according to the LAP learning curve with the economic outcomes of open surgery (OS) for rectosigmoid cancer.

METHODS

A total of 197 patients with rectosigmoid cancer were included in this analysis; 116 received LAP and 81 received OS. Scatter of operative times demonstrated an early learning period of 37 cases in LAP. The following outcomes were compared between LAP and OS during the early learning period and experienced periods; operating room (OR) costs, OR-related hospital profit, total hospital charge, and patient payment. During the median interval of two periods according to the laparoscopic surgery learning curve, there was an inflation rate of about 10% on the medical charges such as operation, radiology, laboratory, and admission fee.

RESULTS

Operating room costs were significantly higher after LAP during the two periods, but the median difference between LAP and OS decreased during the experienced period ($3,055 to $1,850). With increasing operative experience in LAP, the OR-related hospital deficit improved (-$1,072 to-$840). Total hospital charges were significantly higher for LAP than for OS in the early learning period (p < 0.05), but they were similar in the experienced period ($7,983/patient versus $7,045/patient, p > 0.05). During the experienced period, patients paid a lower surcharge for LAP ($1,885-$1,118).

CONCLUSIONS

Total hospital charges for laparoscopic surgery were substantially higher than those of open surgery during the early learning period, but become similar during the experienced period. The shortening of the learning period is a critical factor for achieving cost-effective laparoscopic surgery.

Laparoscopic surgery for colorectal cancer: safe and effective? - A systematic review

OBJECTIVE

To determine the clinical effectiveness of laparoscopic and laparoscopically assisted surgery in comparison with open surgery for the treatment of colorectal cancer.

BACKGROUND

Open resection is the standard method for surgical removal of primary colorectal tumours. However, there is significant morbidity associated with this procedure. Laparoscopic resection (LR) is technically more difficult but may overcome problems associated with open resections (OR).

METHODS

Systematic review and meta-analysis of short- and long-term data from randomised controlled trials (RCTs) comparing LS with OR.

RESULTS

Highly sensitive searches of nine databases identified 19 primary RCTs describing data from over 4,500 participants. Length of hospital stay is shorter, blood loss and pain are less, and return to usual activities is likely to be faster after LR than after OR, but duration of operation is longer. Lymph node retrieval, completeness of resection and quality of life do not appear to differ. No statistically significant differences were observed in rates of anastomotic leakage, abdominal wound breakdown, incisional hernia, wound and urinary tract infections, operative and 30-day mortality, and recurrences, nor in overall and disease-free survival up to three years.

CONCLUSIONS

LR is associated with a quicker recovery in terms of return to usual activities and length of hospital stay with no evidence of a difference in complications or long-term outcomes in comparison to OR, up to three years postoperatively.

Money well spent: a comparison of hospital operating margin for laparoscopic and open colectomies

BACKGROUND

Cost analysis after laparoscopic colectomy has been examined, although reports evaluating the effects of laparoscopy on hospital operating margin are lacking. We compared several cost/revenue measures, including hospital operating margin, between open and laparoscopic colectomies at an academic center.

METHODS

Our cost-accounting database was queried for laparoscopic partial (LPC) and total colectomies (LTC), and open partial (OPC) and total colectomies (OTC) to analyze net revenue, total costs, and total hospital operating margin over a 4-year period. Laparoscopic and open colectomy cases were compared, with mean operating margin as the primary outcome.

RESULTS

From July, 2002 through May, 2006, 842 patients were included for analysis with 138 undergoing laparoscopic colectomy. Net revenue was higher in the LTC group compared with open (US dollars 30,300 vs US dollars 26,800 [P = .02]), and lower in the LPC group (US dollars 15,300 vs US dollars 21,300 open [P < .0001]). Total costs were reduced in both the LPC and LTC groups compared with open [US dollars 11,700 vs US dollars 17,600 [P < .0001] and US dollars 18,000 vs US dollars 19,400 [P = .0019], respectively). LPC resulted in a similar HOM (US dollars 3,602) compared with OPC (US dollars 3,647; P = .35). LTC resulted in a higher HOM (US dollars 12,300) compared with OTC (US dollars 7,400; P = .02).

CONCLUSIONS

LTC generates a significantly higher hospital operating margin than an OTC, although the margins are similar for LPC and OPC.

Laparoscopic surgery in rectal cancer: a prospective analysis of patient survival and outcomes

PURPOSE

The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution.

METHODS

From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method.

RESULTS

A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann's procedure. Mean operating time was 278 (range, 135-430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1-49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5-10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4-43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively.

CONCLUSIONS

Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery.

Laparoscopic intersphincteric resection for low rectal cancer

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with low rectal cancer submitted to laparoscopic intersphincteric resection (ISR). Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Nevertheless, all progress in the development of oncologic therapy (i.e., radiation and chemotherapy), radical surgical removal of the tumour is the only chance for permanent cure of rectal cancer. Beside this main objective, the preservation of faecal continence is the second-most important goal to reach an acceptable quality of life with preservation of sphincter function. Information concerning the depth of tumour penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection with ISR allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Data from small, non-randomized studies evaluating laparoscopic ISR suggest that this procedure is feasible by experienced surgeons. A literature search identified five studies [Uchikoshi F, Nishida T, Ueshima S, Nakahara M, Matsuda H. Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure. Tech Coloprocto 2006;10:5-9; Bretagnol F, Rullier E, Couderc P, Rullier A, Saric J. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Disease 2003;5:451-3; Rullier E, Sa Cunha A, Couderc P, Rullier A, Gontier R, Saric J. Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. British Journal of Surgery 2003;90:445-51; Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Diseases of the Colon and Rectum 2000;43(Suppl. 10):S94-7; Miyajima N, Yamakawa T. Laparoscopic surgery for early rectal carcinoma. Nippon Geka Gakkai Zasshi 1999;100:801-5]. The aim was to find those studies that documented potential clinical application of laparoscopic ISR. These studies concluded that a laparoscopic approach can be considered in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery. Hopefully, randomized controlled trials, which utilize these alternative procedures, will in future determine the results of laparoscopic ISR in terms of sphincter function, faecal continence, disease free and overall survival. The reviewed studies concluded that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined.

Is laparoscopic colectomy for cancer cost-effective relative to open colectomy?

BACKGROUND

Laparoscopic-assisted colectomy (LAC) for cancer has been shown to be safe, with equivalent long-term survival rates to conventional open colectomy (OC) and better short-term patient outcomes. However, LAC tends to require more operating theatre time and disposable equipment. This study investigated, in the context of the New Zealand public hospital system, the extent to which LAC for cancer is cost-effective relative to OC.

METHODS

Estimates of the hospital resources used and patient recovery times for LAC and OC for colorectal cancer were obtained from a meta-analysis of published international randomized controlled trials. Using prices from a representative New Zealand public hospital, the additional resources for LAC (relative to OC) were summed to obtain an estimate of LAC's total incremental (additional) cost. The recovery time savings from LAC were also represented in quality-adjusted life years (QALY), enabling a cost-utility analysis of LAC, which was subjected to a one-way sensitivity analysis.

RESULTS

On average, a LAC costs New Zealand public hospitals $1267 (range: $259-$3808; all dollars referred to are New Zealand dollars) more than an OC. Average recovery time savings of 12 and 33 days (from two randomized controlled trials) translate into QALY gains of 0.018 and 0.049. Thus, relative to an OC, an LAC costs $38 and $106 per recovery day saved, or $70 389 and $25 857 (combined range: $14 389-$211 556) per QALY gained.

CONCLUSION

LAC for cancer appears to be cost-effective relative to OC (per recovery day saved and QALY gained, respectively) for the lower of the average cost estimates and is probably not cost-effective for the higher estimate. Expected future reductions in operating times, conversion rates and postoperative stays will further improve cost-effectiveness.

Internal herniation through the mesenteric opening after laparoscopy-assisted right colectomy: report of a case

We discuss a rare complication in a patient who underwent laparoscopic colectomy. A 69-year-old woman underwent laparoscopy-assisted right colectomy for cancer of the ascending colon. Two months after the operation, bowel obstruction developed. Decompression with a long intestinal tube failed to resolve the obstruction. Thus, surgery was performed. Abdominal exploration revealed a strangulated ileal loop caused by herniation through the mesenteric opening at the anastomotic site. The mesenterium had not been sutured during the previous operation. The anastomotic segment had twisted semicircularly and adhered to the retroperitoneum, so the mesenteric opening had narrowed.

Laparoscopic resection for colorectal cancer in octogenarians: results in a decade

OBJECTIVES

This study was designed to evaluate the results of laparoscopic resection for colorectal cancer in octogenarians.

METHODS

Patients aged 80 years or older who underwent elective laparoscopic resection for colorectal cancer from July 1, 1996 to June 30, 2006 were recruited for analysis, with the following exceptions: 1) patients who did not give informed consent; 2) unfit for operative treatment; 3) presented as surgical emergencies; 4) multiple previous abdominal operations; or 5) locally advanced tumors. Operating time, blood loss, length of hospital stay, mortality and morbidities, including anastomotic dehiscence, pulmonary and wound sepsis, disease recurrence, and patient survival were used to measure outcome.

RESULTS

During a ten-year period, laparoscopic colorectal cancer resection was attempted in 101 octogenarians. The median age was 83 (range, 80-95) years and 45 patients were males. The median operating time was 110 (range, 60-245) minutes, with a median blood loss of 50 (range, 0-1,000) ml. Conversion was required in only one case with a leakage rate of 3.3 percent. The overall morbidity and operative mortality rate were 17 and 3 percent, respectively. With a median follow-up of 24 (range, 0-102) months, 22 patients developed recurrence, with 8 of those still surviving. The overall five-year survival is 51 percent.

CONCLUSIONS

Our experience confirms that laparoscopic colorectal cancer resection in selected octogenarians is safe and feasible. Aside from the obvious short-term benefits, the long-term oncologic outcomes are favorable.

Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon

BACKGROUND

The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. However the results of a large series by a single surgeon in a single center have yet to be reported. We reviewed the short-term outcome of our series of laparoscopic colorectal procedures to better define the learning curve for acquiring these skills.

METHODS

Four hundred four patients with a colorectal neoplasm underwent laparoscopic surgery between August 1998 and December 2005. Surgery was performed under 8 to 10 cm H(2)O CO(2) pneumoperitoneum. Type of operation, time of operation, and estimated blood loss were compared for each level of lymph node dissection, and the rate and reason for conversion to open procedures were determined. Time to passage of flatus, hospital stay, and postoperative complications were recorded. The learning curve for right hemicolectomy, sigmoidectomy, and low anterior resection was calculated.

RESULTS

Open conversion was required in 13 patients (3.2%). Uncontrollable bleeding occurred in four cases, and inability to divide the rectum because of adhesions or local invasion occurred in three. The time of operation for D3 level lymph node dissection was longer than for D2 in ileocecal resection, right hemicolectomy, and sigmoidectomy. Estimated blood loss was similar among the different types of operation. Blood loss of last 40 right hemicolectomies was less than in the first 40 cases, and the incidence of intraoperative complications in the first 40 sigmoidectomies was higher than subsequent cases. Time of operation, estimated blood loss, and number of complications did not change over time for low anterior resection.

CONCLUSION

The large series performed by a single surgeon is consistent with large multicenter studies that have validated the superiority of laparoscopic colorectal surgery over conventional open procedures. The learning curve flattens out after about 40 cases of right hemicolectomy and sigmoidectomy.

[Minimally invasive surgery and the economics of it. Can minimally invasive surgery be cost efficient from a business point of view?]

Minimally invasive surgery (MIS) is now accepted as equally valid as the use of a standard access in some areas of surgery. It is not possible to decide whether this access is economically worthwhile and if so for whom without a full economic cost-benefit analysis, which must take account of the hospital's own characteristics in addition to the cost involved for surgery, staff, infrastructure and administration. In summary, the main economic advantage of MIS lies in the patient-related early postoperative results, while the main disadvantage is that the operative material costs are higher. At present, the payment made for each procedure performed under the DRG system includes 14-17% of the total cost for materials, regardless of the access route and of the technical sophistication of the operation. The actual material costs are greater by a factor of 2-50 for MIS than for a conventional procedure. The task of the hospital is thus to lower the costs for material and infrastructure; that of industry is to offer less expensive alternatives; and that of our politicians, to implement better remuneration of the material costs.

Laparoscopic colorectal surgery - results from 200 patients

OBJECTIVE

Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years.

METHOD

A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest.

RESULTS

Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge.

CONCLUSION

Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.

Credentialing for Laparoscopic Bowel Operation: There Is No Substitute for Knowing the Outcomes

BACKGROUND

Case volume and training have been considered as reasonable surrogates for competency that can be used as a basis to grant privileges for performing laparoscopic operations. To determine the validity of this practice, we assessed the relationship of surgical volume and training to provider-related complications after laparoscopic bowel resection.

STUDY DESIGN

All patients undergoing open or laparoscopic resection at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained database. Complications were recorded by a specially trained nurse practitioner and adjudicated monthly by a team of gastrointestinal surgeons. Surgeon case volume, training, and operative indication were assessed for their ability to predict technical complications after laparoscopic resection using a logistic regression model.

RESULTS

Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis.

CONCLUSIONS

Surgeon case volume and training had no relationship to the complication rate after laparoscopic bowel operation. Case selection is a critical confounding variable because surgeons vary so greatly in their indications for using laparoscopic technique. Although documentation of training is appropriately considered in granting privileges, actually tracking outcomes is likely the only reliable way to assess competency.

Short-term outcomes after robotic-assisted total mesorectal excision for rectal cancer

BACKGROUND

Laparoscopic total mesorectal excision for rectal cancer remains a difficult procedure with high conversion rates. We have sought to improve on some of the pitfalls of laparoscopy by using the DaVinci robotic system. Here we report our two-year experience with robotic-assisted laparoscopic surgery for primary rectal cancer.

METHODS

A prospectively maintained database of all rectal cancer cases starting in November 2004 was created. A series of 39 consecutive unselected patients with primary rectal cancer was analyzed. Clinical and pathologic outcomes were reviewed retrospectively.

RESULTS

22 patients had low anterior, 11 intersphincteric and six abdominoperineal resections. Postoperative mortality and morbidity were % and 12.8%, respectively. The median operative time was 285 minutes (range 180-540 mins). The conversion rate was 2.6%. A total mesorectal excision with negative circumferential and distal margins was accomplished in all patients, and a median of 13 (range 7-28) lymph nodes was removed. The anastomotic leak rate was 12.1%. The median hospital stay was 4 days. There have been no local recurrences at a median follow-up of 13 months.

CONCLUSIONS

Robotic-assisted surgery for rectal cancer can be carried out safely and according to oncological principles. This approach shows promising short-term outcomes and may facilitate the adoption of minimally invasive rectal surgery.

Environmental impact of accelerated clinical care in a high-volume center

BACKGROUND

"Fast-track" surgery, involving multimodal care, improves efficiency and short-term outcomes in patients undergoing bowel resection. The sustainability of the benefits and the "drag" effect on non-participating surgeons through changed nursing and resident practice is undetermined.

METHODS

297 consecutive elective colon resections (DRG149) within three study periods (pre-change, immediate post-change, long-term post-change) were retrospectively reviewed. Two surgeons began to "fast-track" their patients in 1999 independently from the other surgeons in the hospital. Surgeons were grouped into "fast-track surgeons," "high-volume surgeons," (>/=10 cases per year) and "low-volume surgeons," (<10 cases per year). Comparisons of duration of stay (DOS), readmission rates, and mortality were made for each of three time periods and surgeon groups. Trends were also compared with unrelated hospital non-colectomy control groups (uncomplicated craniotomy DRG 001 and pancreatic surgery DRG 192) and to a colectomy control group from a statewide database (DRG 149).

RESULTS

Mean DOS for colon resection significantly decreased among the "fast-track" surgeons and among all the other surgeons in the hospital, from 6.3 +/- 0.3 days, down to 3.7 +/- 0.1 days. We found no significant difference in mortality or readmission rates between the study periods. 15% of the cases were performed laparoscopically, and the improvements in outcome were independent of surgical technique. Control group analyses demonstrated that the environmental impact on outcome was independent of hospital-wide or regional improvement efforts.

CONCLUSIONS

Implementation of a new practice pattern in a shared environment leads to improved outcomes for patients of other surgeons within the same environment. Dissemination and cross-pollination of new methods through resident, nurse, and case manager practice pattern modification creates a favorable force for change and this impact is sustained over a 3-year period.

Laparoscopic vs. open total mesorectal excision in unselected patients with rectal cancer: impact on early outcome

PURPOSE

This study was designed to compare laparoscopic vs. open total mesorectal excision for cancer of the rectum on perioperative outcome and quality of life.

METHODS

A total of 187 consecutive unselected patients with rectal cancer who underwent total mesorectal excision during a seven-year period were prospectively evaluated. Patients were monitored 30 days for postoperative complications. Quality of life was evaluated before and at one year after surgery.

RESULTS

A total of 108 patients underwent laparoscopic total mesorectal excision, whereas 79 underwent open. Conversion rate was 12 percent. In the laparoscopic group, operating time was 33 minutes longer (P = 0.03) and intraoperative blood loss was lower (P = 0.001). Tumor stage and the number of lymph nodes that were intraoperatively collected were similar in the two groups. The overall morbidity rate was 29.6 percent in the laparoscopic and 27.8 percent in the open (P = 0.78) group. No patient died during the postoperative period. Anastomotic leak rate was similar in the two groups (14.8 percent in laparoscopic vs. 12.6 percent in open; P = 0.88). Patients in the laparoscopic group recovered earlier bowel function (P = 0.01) and experienced a shorter length of stay (P = 0.003). At one-year follow-up, overall quality of life was similar in the two groups. In the laparoscopic group, social functioning item was significantly better (P = 0.05) and trend to a better physical status was observed (P = 0.07).

CONCLUSIONS

Laparoscopic total mesorectal excision is safe and feasible, does not jeopardize the complication rate, and has the benefits of much less blood during the operation and shorter hospitalization.

Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group

PURPOSE

The aim of the current study is to report the long-term outcomes after laparoscopic-assisted surgery compared with conventional open surgery within the context of the UK MRC CLASICC trial. Results from randomized trials have indicated that laparoscopic surgery for colon cancer is as effective as open surgery in the short term. Few data are available on rectal cancer, and long-term data on survival and recurrence are now required.

METHODS

The United Kingdom Medical Research Council Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (UK MRC CLASICC; clinical trials number ISRCTN 74883561) trial study comparing conventional versus laparoscopic-assisted surgery in patients with cancer of the colon and rectum. The randomization ratio was 2:1 in favor of laparoscopic surgery. Long-term outcomes (3-year overall survival [OS], disease-free survival [DFS], local recurrence, and quality of life [QoL]) have now been determined on an intention-to-treat basis.

RESULTS

Seven hundred ninety-four patients were recruited (526 laparoscopic and 268 open). Overall, there were no differences in the long-term outcomes. The differences in survival rates were OS of 1.8% (95% CI, -5.2% to 8.8%; P = .55), DFS of -1.4% (95% CI, -9.5% to 6.7%; P = .70), local recurrence of -0.8% (95% CI, -5.7% to 4.2%; P = .76), and QoL (P > .01 for all scales). Higher positivity of the circumferential resection margin was reported after laparoscopic anterior resection (AR), but it did not translate into an increased incidence of local recurrence.

CONCLUSION

Successful laparoscopic-assisted surgery for colon cancer is as effective as open surgery in terms of oncological outcomes and preservation of QoL. Long-term outcomes for patients with rectal cancer were similar in those undergoing abdominoperineal resection and AR, and support the continued use of laparoscopic surgery in these patients.

Clinical outcome of the laparoscopic surgery for stage II and III colorectal cancer

BACKGROUND

Laparoscopic colorectal cancer surgery has become widely accepted recently. However, the oncological validity of this surgery has not yet been well analyzed, especially for advanced cancer. The aim of this study is to assess the clinical outcome of laparoscopic surgery for stage II/III colorectal cancer in our hospital.

PATIENTS AND METHODS

Between June 1999 and August 2006, 321 patients underwent laparoscopic colorectal cancer surgery in our hospital; of those 121 cases whose pathological findings revealed stage II/III were included in this study. Among these cases, we assessed a short-term outcome and a medium-term outcome in terms of survival evaluation.

RESULTS

The male:female ratio was 73:48, and mean age of patients was 62.4 years. Thirteen tumors were located in the cecum, 29 in the ascending colon, five in the transverse colon, one in the descending colon, 43 in the sigmoid colon, and 30 in the rectum. Average duration of operation was 184 minutes, and mean estimated blood loss was 53.5 ml. Five patients (4.1%) were converted to open procedures. No intraoperative complication was observed but eight complications (6.6%) occurred postoperatively. Forty-two cases were classified as stage II, 62 as stage IIIA /B, and 17 as stage IIIC. Five patients died of cancer relapse (4.1%), and 18 cases had recurrence of disease (14.9%), to date. No port-site recurrence was detected. Overall five-year survival was 95.7% in stage II, 84.1% in stage IIIA/B, 70.0% in stage IIIC. Meanwhile disease-free five-year survival was 75.6% in stage II, 80.1% in stage IIIA/B, and 66.8% in stage IIIC. No significant difference was observed between stages, in terms of either overall or disease-free survival.

CONCLUSION

Although further evaluation is required, laparoscopic surgery for stage II/III colorectal cancer is safe and would be an oncologically adequate procedure.

Laparoscopic approach in surgical treatment of rectal cancer

Background

High rates of conversion to open operation and morbidity have been reported after laparoscopic total mesorectal excision (TME) with sphincter preservation for rectal cancer. This study examined risk factors for conversion and morbidity to determine which patients with rectal cancer could benefit from a laparoscopic resection.

Methods

Two hundred patients (117 men) with mid and low rectal cancer treated by laparoscopic TME were studied. The impact of clinical and pathological characteristics on conversion and complications was assessed by multivariable analysis.

Results

Reconstruction after TME included 79 low colorectal and 121 coloanal anastomoses. Conversion was necessary in 31 patients (15·5 per cent), and was independently associated with sex, type of anastomosis and intraoperative rectal fixity. Postoperative morbidity in 50 patients (25·0 per cent) was independently associated with sex and type of anastomosis. Men with a stapled anastomosis had a threefold higher rate of conversion (13 (34 per cent) of 38 versus 18 (11·1 per cent) of 162; P &lt; 0·001) and morbidity (22 (58 per cent) versus 28 (17·3 per cent); P &lt; 0·001) than other patients.

Conclusion

Laparoscopic TME is a good option for women and for men treated by coloanal anastomosis. Technical improvement of laparoscopic stapling is needed before the laparoscopic approach can be offered to all patients.

Synchronous Laparoscopic Resection of Colorectal and Renal/Adrenal Neoplasms

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.

Hand-Assisted Laparoscopic Colectomy Compared with Open Colectomy in a Nontertiary Care Setting

BACKGROUND

Laparoscopic colectomy allows oncologic resection equivalent to open colectomy while reducing postoperative morbidity, at the cost of longer operating time. Hand-assisted laparoscopy might yield the benefits of laparoscopy while reducing operating time.

PATIENTS AND METHODS

We compared the intraoperative and postoperative experience of patients undergoing hand-assisted laparoscopic colectomy (HALC) to those who had open colectomy. In this retrospective case review of consecutive patients undergoing HALC for colon tumors from April 2003 to September 2004 compared with patients who had open colectomy, patients with rectal cancer and stage IV disease were excluded, and reported variables were compared by the nonparametric Mann-Whitney U test; all P values are 2-tailed.

RESULTS

The number of patients with HALC versus open colectomy was 39 and 55, respectively. The locations of tumors were as follows: right colon, 62% versus 56%; left colon, 2.5% versus 11%; sigmoid colon, 31% versus 33%; and rectosigmoid colon, 5% versus 0. Stage distribution was as follows: stage 0, 23% versus 11%; stage I, 23% versus 23%; stage II, 31% versus 36%; and stage III, 23% versus 31%. Median operating room time was 139 minutes versus 137 minutes (P = 0.94). Four 39 (10%) HALC procedures were converted to open colectomy. Duration of hospitalization was 6 days versus 10 days (P = 0.007). Median number of lymph nodes in resection specimen was 12 versus 9 (P = 0.043). There were 3 cases of serious postoperative infection in the HALC group versus 9 in the open colectomy cohort.

CONCLUSION

Hand-assisted laparoscopic colectomy is technically feasible in the nontertiary care setting, with duration of surgery equivalent to that of open colectomy but significantly shorter duration of hospitalization and equivalent or superior quality resection and pathologic staging.

Systematic review of the costs of laparoscopic colorectal surgery

PURPOSE

Recent studies have confirmed the clinical efficacy of laparoscopic colorectal surgery; however, its use has not become widespread. One reason for this is perceived economic implications. A systematic review was undertaken examining the costs of laparoscopic colorectal surgery.

METHODS

Electronic databases were searched for articles comparing laparoscopic colorectal surgery and open surgery. Primary outcome measures were operating room, direct hospital, and indirect costs. Secondary outcomes were conversion rates and length of hospital stay. The percentage difference in costs was used for comparisons between studies.

RESULTS

Twenty-nine articles were identified in which cost data were presented (total number of patients 3,681); the economic data in most studies was limited. Operating room costs were greater for laparoscopic colorectal surgery than open surgery in all studies (median difference, 50 percent; interquartile range, 27-78 percent; P < 0.001). There was no overall difference in total hospital costs (median difference, 0 percent; interquartile range, -17.5 to 21 percent). Only two articles collected data on indirect costs, with both in favor of laparoscopic colorectal surgery. Hospital stay was shorter for laparoscopic colorectal surgery in all studies (median difference, 2.8 days; interquartile range, 1.3-3.7; P < 0.001). Median conversion rate was 7.8 percent (mean, 14 percent; interquartile range, 6-21 percent).

CONCLUSIONS

Operating room costs are greater for laparoscopic colorectal surgery than open surgery. Total hospital costs are similar. There may be societal benefits associated with lower indirect costs for laparoscopic colorectal surgery. Cost should not be a deterrent to performing laparoscopic colorectal surgery.

Factors affecting the number of lymph nodes retrieved in colorectal cancer specimens

BACKGROUND

Staging of colorectal cancer is dependent on the number of lymph nodes in a surgical specimen that are positive for metastatic cancer. It is generally recommended that a minimum of 12 lymph nodes be examined to ensure adequate staging. It is unclear which factors specifically contribute to variation in the number of lymph nodes retrieved from surgical specimens. This study aims to understand the factors affecting the number of lymph nodes identified in surgical colorectal cancer specimens.

METHODS

A total of 264 retrospectively collected cases of colorectal cancer surgically treated at the University Health Network in Toronto from 2004 to 2006 were analyzed. We used univariate analyses of variance (ANOVA), and univariate and multivariable linear and logistic regression analyses to study variation in the lymph node number associated with a variety of explanatory variables.

RESULTS

The average number of lymph nodes retrieved per case was 18.1, with 70 (26.5%) cases containing fewer than 12. Variation in the lymph node number was greatest between different pathology assistants (p = or< 0.001). The mean number of nodes retrieved by different pathology assistants ranged from 12.6 to 29.7. On average, surgery for recurrent cancer removed 6.0 (95% CI 1.2 to 10.9, p = 0.02) fewer lymph nodes than for primary cancer. Each additional year of patient age was associated with retrieval of 0.1 (95% CI 0.04 to 0.2, p = 0.005) fewer nodes, and rectal cancer specimens had 2.7 (95% CI 0.04 to 5.4, p = 0.05) fewer lymph nodes than colon cancer specimens.

CONCLUSION

Most of the variation in the number of lymph nodes identified in surgical specimens from colorectal cancer operations was accounted for by differences between pathology assistants.

Wound infection after elective laparoscopic surgery for colorectal carcinoma

BACKGROUND

The aim of this study was to evaluate various clinical parameters that would influence the occurrence of wound infection (WI) in elective laparoscopic surgery (LS) for colorectal carcinoma.

METHODS

The study included 290 patients who underwent LS between June 2001 and December 2005. WI was diagnosed within 30 days of the operation, and both superficial and deep incision surgical site infection were evaluated together.

RESULTS

Eighteen (6.2%) were diagnosed with WI. Of the infected patients, nine (50%) had WI at the extraction site, six (33%) at the port site of the drainage tube, and three (17%) at the supraumbilical incision. Following bivariate analysis, the variables of stoma creation, intraoperative hypotension, and length of operation were selected for multivariate analysis as their P values were <0.2, the predominant cutoff, and stoma creation and intraoperative hypotension were independently predictive of developing WI. Regarding the duration of postoperative hospital stay, there was no significant difference between patients with or without WI.

CONCLUSIONS

Stoma creation and intraoperative hypotension were independent risk factors for WI. The results obtained in this study should be considered in an effort to prevent WI in LS for colorectal carcinoma, although these risk factors need further evaluation.

Telerobotic-assisted laparoscopic abdominoperineal resection for low rectal cancer: Report of the first case in Hong Kong and China with an updated literature review

Telerobotic surgery is the most advanced development in the field of minimally invasive surgery. The da Vinci surgical system, which is currently the most widely used telerobotic device, was approved by the Food and Drug Administration of the United States of America for clinical use in all abdominal operations in July 2000. The first da Vinci surgical system in China was installed in November 2005 at our institution. We herein report the first telerobotic-assisted laparoscopic abdominoperineal resection using the 3-arm da Vinci surgical system for low rectal cancer in Hong Kong and China, which was performed in August 2006. The operative time and blood loss were 240 min and 200 mL, respectively. There was no complication, and the patient was discharged on postoperative day five. An updated review of published literature on telerobotic-assisted colorectal surgery is included in this report, with special emphasis on its advantages and limitations.

Laparoscopic colon surgery in community practice

BACKGROUND

The benefits of laparoscopic colon surgery have been shown in the literature. More recently, the oncologic outcomes have been shown to be similar in the laparoscopic group when compared with open colon surgery for colon cancer. However, most of the published literature is from university/academic institutions. There is limited literature on laparoscopic colon surgery from a community hospital.

METHODS

A retrospective chart review was conducted of 62 laparoscopic colon surgeries from a single surgeon's practice in a community hospital from October 27, 2003, to August 31, 2006. The laparoscopic approach was performed on patients with benign and curative colon cancer. The primary outcome measures were length of operating room times, pathologic results, length of hospital stay, and complication rates.

RESULTS

Of the 62 laparoscopic patients, there were 9 converted patients (14% conversion rate). There were no perioperative deaths, and no anastomotic leaks. The average length of operating room time was 190 minutes (range, 96-295 min). The median length of hospital stay was 4 days (range, 3-17 d). There were 40 laparoscopic patients for colon cancer. The resection margins all were negative, and the mean number of lymph nodes in the resected specimen was 17 (range, 5-37). The overall complication rate was 18%.

CONCLUSIONS

This study showed that laparoscopic colon surgery is technically feasible in a community hospital. The results from this study are similar to the published literature from university/academic institutions.

Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery

BACKGROUND

Laparoscopic colorectal surgery has been claimed to enhance recovery when compared with open surgery. The aim of our study was to investigate whether laparoscopic colorectal resection improved recovery with the use of a multimodal rehabilitation programme.

METHOD

We carried out a prospective audit of 80 patients undergoing elective colorectal resection between November 2003 and March 2005. All patients underwent a fast-track protocol with early feeding, mobilization and a fluid and sodium restriction regime. Recovery was measured in terms of return of gastrointestinal function, hospital stay, complications and quality of life measures.

RESULTS

Of the 80 patients in the study 22 underwent laparoscopic resection and 58 had open surgery. Patients were well matched for all baseline characteristics. The groups were not significantly different in terms of opioid or antiemetic use. They were also similar in median time to first flatus (69 h vs 69 h, P = 0.36) and median time to first bowel motion (127 h vs 101 h, P = 0.07). There was no difference in median hospital stay (5.8 days vs 5.9 days, P = 0.87) or complications (P = 0.46) between the laparoscopic and open group. There were no significant differences in Short Form 36 scores between the two groups for any of the components measured.

CONCLUSION

Laparoscopic colorectal resection does not appear to reduce the duration of ileus or hospital stay with the use of a multimodal rehabilitation regime. Further large randomized trials are required to confirm these findings.