Is the laparoscopic approach to colectomy safe for the morbidly obese?

The feasibility and outcomes of metabolic and bariatric surgery prior to neoplastic therapy

BACKGROUND

Metabolic and bariatric surgery (MBS) is a potent intervention for addressing obesity-related medical conditions and achieving sustainable weight loss. Beyond its conventional role, MBS has demonstrated potential to serve as a transitional step for patients requiring various interventions. However, the implications of MBS in the context of neoplasia remain understudied.

OBJECTIVES

To explore the feasibility of MBS as a possible attempt to reduce surgical and treatment risks in patients with benign tumors or low-grade cancers.

SETTING

Multicenter review from twelve tertiary referral centers spanning 8 countries.

METHODS

A retrospective review of patients with a diagnosis of primary neoplasia, deemed inoperable or high-risk due to obesity, and receiving primary MBS prior to neoplastic therapy. Data encompassed baseline characteristics, neoplasia characteristics, MBS outcomes, and neoplastic therapy outcomes.

RESULTS

Thirty-seven patients (median age 52 years, 75.7% female, median BMI of 49.1 kg/m2) were included. There were 9 distinct organs of origin of primary neoplasia, with the endometrium (43.2%) being the most common, followed by the pancreas, colon, kidney and breast. Sleeve gastrectomy (SG) was the most commonly performed MBS procedure (78.4%), with no MBS-related complications or mortalities reported over an average of 4.3 ± 3.9 years. Thirty-one patients (83.8%) eventually underwent neoplastic surgery, with a mean BMI decrease from 49.9 kg/m2 to 39.7 kg/m2 at surgery over an average of 5.8 ± 4.8 months. There were 2 (6.7%) documented mortalities associated with neoplastic surgical intervention.

CONCLUSIONS

This study highlights the potential feasibility of employing MBS prior to neoplastic therapy in patients with low-grade, less aggressive neoplasms in the context of obesity. This underscores the importance of providing a personalized, case-to-case multidisciplinary approach in the management of these patients.

Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis

BACKGROUND

Obesity can pose perioperative challenges related to obesity-associated co-morbidities and technical factors. However, the true impact of obesity on postoperative outcomes is not well established and reports are conflicting. The aim was to perform a systematic review and meta-analysis to explore the effect of obesity on perioperative outcomes for general surgery procedures in distinct obesity subtypes.

METHODS

A systematic review was performed for studies reporting postoperative outcomes in relation to BMI in upper gastrointestinal, hepatobiliary and colorectal based on an electronic search using the Cochrane Library, Science Direct, PubMed and Embase up to January 2022. The primary outcome was the incidence of 30-day postoperative mortality among patients with obesity undergoing general surgical procedures in comparison to patients with normal range BMI.

RESULTS

Sixty-two studies, including 1 886 326 patients, were eligible for inclusion. Overall, patients with obesity (including class I/II/II) had lower 30-day mortality rates in comparison to patients with a normal BMI (odds ratio (OR) 0.75, 95 per cent c.i. 0.66 to 0.86, P < 0.0001, I2 = 71 per cent); this was also observed specifically in emergency general surgery (OR 0.83, 95 per cent c.i. 0.79 to 0.87, P < 0.0000001, I2 = 7 per cent). Compared with normal BMI, obesity was positively associated with an increased risk of 30-day postoperative morbidity (OR 1.11, 95 per cent c.i. 1.04 to 1.19, P = 0.002, I2 = 85 per cent). However, there was no significant difference in postoperative morbidity rates between the cohorts of patients with a normal BMI and class I/II obesity (OR 0.98, 95 per cent c.i. 0.92 to 1.04, P = 0.542, I2 = 92 per cent). Overall, the cohort with obesity had a higher rate of postoperative wound infections compared with the non-obese group (OR 1.40, 95 per cent c.i. 1.24 to 1.59, P < 0.0001, I2 = 82 per cent).

CONCLUSION

These data suggest a possible 'obesity paradox' and challenge the assumption that patients with obesity have higher postoperative mortality compared with patients with normal range BMI. Increased BMI alone is not associated with increased perioperative mortality in general surgery, highlighting the importance of more accurate body composition assessment, such as computed tomography anthropometrics, to support perioperative risk stratification and decision-making.

REGISTRATION NUMBER

CRD42022337442 (PROSPERO https://www.crd.york.ac.uk/prospero/).

Results of laparoscopic resection in high-risk rectal cancer patients

PURPOSE

Obesity, neoadjuvant-radiotherapy, tumour proximity to the anal verge and previous abdominal surgery are factors that might increase the intra-operative difficulty of laparoscopic rectal cancer surgery. However, whether patients with these 'high-risk' characteristics are subject to worse short- or long-term outcomes is debated. The aim of this study is to examine the short- and long-term clinical and oncological outcomes of patients receiving laparoscopic rectal surgery with any of these high-risk characteristics and compare them with patients that do not possess any of these high-risk features.

METHODS

For the purpose of this study data from consecutive patients receiving laparoscopic rectal cancer resections between 2006 and 2016 from two centres were analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI ≥ 30, neoadjuvant chemoradiotherapy, tumour < 8 cm from the anal verge and previous abdominal surgery.

RESULTS

A total of 313 patients were identified (227 high risk, 86 low risk). Short-term outcomes were similar between the two groups with the exception of blood loss and length of stay, which were higher in the high-risk group (10 vs 2.5 ml, p = 0.045; 7 vs 5 days, p = 0.001). There were no statistically significant differences in 5-year overall survival (79.7% vs 79.8%, p = 0.757), disease-free survival (76.8% vs 69.3%, p = 0.175), distant disease-free interval (84.8% vs 79.7%, p = 0.231) and local recurrence-free interval (100%, 97.4%, p = 0.162) between the two groups.

CONCLUSION

Similar short- and long-term outcomes can be achieved in high-risk and low-risk patients receiving laparoscopic rectal surgery. The presented data support the suitability of laparoscopic surgery for this group of patients.

Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study

PURPOSE

Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients.

METHODS

All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined.

RESULTS

A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033).

CONCLUSIONS

In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.

Minimally invasive colorectal surgery in the morbid obese: does size really matter?

BACKGROUND

As obesity becomes more prevalent, it presents a technical challenge for minimally invasive colorectal resection surgery. Various studies have examined the clinical outcomes of obese surgical patients. However, morbidly obese patients (BMI ≥ 35) are becoming increasingly more common. This study aims to investigate the short-term surgical outcomes of morbidly obese patients undergoing minimal-invasive colorectal surgery and compare them with both obese (30 ≤ BMI < 35) and non-obese patients (BMI < 30).

METHODS

Patients from three centres who received minimally invasive colorectal surgical resections between 2006 and 2016 were identified from prospectively collected databases. The baseline characteristics and surgical outcomes of morbidly obese, obese and non-obese patients were analysed.

RESULTS

A total of 1386 patients were identified, 84 (6%) morbidly obese, 246 (18%) obese and 1056 (76%) non-obese. Patients' baseline characteristics were similar for age, operating surgeon, surgical approach but differed in terms of ASA grade and gender. There was no difference in conversion rate, length of stay, anastomotic leak rate and 30-day readmission, reoperation and mortality rates. Operation time and blood loss were different across the 3 groups (morbidly obese vs obese vs non-obese: 185 vs 188 vs 170 min, p = 0.000; 20 vs 20 vs 10 ml, p = 0.003). In patients with malignant disease there was no difference in lymph node yield or R0 clearance. Univariate and multivariate linear regression analysis showed that for every one-unit increase in BMI operative time increases by roughly 2 min (univariate 2.243, 95% CI 1.524-2.962; multivariate 2.295; 95% CI 1.554-3.036). Univariate and multivariate binary logistic regression analyses showed that BMI does not affect conversion or morbidity and mortality.

CONCLUSIONS

The increased technical difficulty encountered in obese and morbidly obese patients in minimally invasive colorectal surgery results in higher operative times and blood loss, although this is not clinically significant. However, conversion rate and post-operative short-term outcomes are similar between morbidly obese, obese and non-obese patients.

Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients

Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m²) ≥30 were defined as obese, and patients with a BMI (kg/m²) <30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman group: A). In group A, the Laparoscopic Caiman 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman group than in the Historical group [104 vs 124 min (p 0.004), 116 vs 140 min (p 0.004), and 125 vs 151 min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman group than in the historical one [52 ml vs 93 for RC (p 0.003); 65 vs 120 ml for LC (p 0.001); 93 vs 145 ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BACKGROUND

Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

METHODS

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases.

RESULTS

During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

CONCLUSIONS

Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.

Laparoscopic colectomy in the obese, morbidly obese, and super morbidly obese: when does weight matter?

PURPOSE

Previous studies have demonstrated that obese patients (BMI >30) undergoing laparoscopic colectomy have longer operative times and increased complications when compared to non-obese cohorts. However, there is little data that specifically evaluates the outcomes of obese patients based on the degree of their obesity. The aim of this study was to evaluate the impact of increasing severity of obesity on patients undergoing laparoscopic colectomy.

METHODS

A retrospective review was performed of all patients undergoing laparoscopic colectomy between 1996 and 2013. Patients were classified according to their BMI as obese (BMI 30.0-39.9), morbidly obese (BMI 40.0-49.9), and super obese (BMI >50). Main outcome measures included conversion rate, operative time, estimated blood loss, post-operative complications, and length of stay.

RESULTS

There were 923 patients who met inclusion criteria. Overall, 604 (65.4%), 257 (27.9%), and 62 (6.7%) were classified as obese (O), morbidly obese (MO), and super obese (SO), respectively. Clinicopathologic characteristics were similar among the three groups. The SO group had significantly higher conversion rates (17.7 vs. 7 vs. 4.8%; P = 0.031), longer average hospital stays (7.1 days vs. 4.9 vs. 3.4; P = 0.001), higher morbidity (40.3 vs. 16.3 vs. 12.4%; P = 0.001), and longer operative times (206 min vs. 184 vs. 163; P = 0.04) compared to the MO and O groups, respectively. The anastomotic leak rate in the SO (4.8%; P = 0.027) and MO males (4.1%; P = 0.033) was significantly higher than MO females (2.2%) and all obese patients (1.8%).

CONCLUSION

Increasing severity of obesity is associated with worse perioperative outcomes following laparoscopic colectomy.

BMI as a Predictor for Perioperative Outcome of Laparoscopic Colorectal Surgery: a Pooled Analysis of Comparative Studies

BACKGROUND

There has been a long-lasting controversy about whether higher BMI is associated with worse perioperative outcomes of laparoscopic colorectal surgery. Recently, a number of newly published investigations have made it possible to draw a quantitative conclusion.

OBJECTIVE

We conducted this comprehensive meta-analysis to clarify the exact effect that BMI imposes on perioperative outcome of laparoscopic colorectal surgery.

DATA SOURCES

We systematically searched MEDLINE, Embase, and Cochrane Library databases to identify all relevant studies.

STUDY SELECTION

Comparative studies in English that investigated perioperative outcome of laparoscopic colorectal surgery for patients with different BMIs were included. Quality of studies was evaluated by using the Newcastle-Ottawa Scale.

INTERVENTION

The risk factor of interest was BMI.

MAIN OUTCOME MEASURES

Effective sizes were pooled under a random-effects model to evaluate preoperative, intraoperative, and postoperative outcomes.

RESULTS

A total of 43 studies were included. We found that higher BMI was associated with significantly longer operative time (p < 0.001), greater blood loss (p = 0.01), and higher incidence of conversion to open surgery (p < 0.001). Moreover, BMI was a risk factor for overall complication rates (p < 0.001), especially for ileus (p = 0.02) and events of the urinary system (p = 0.03). Significant association was identified between higher BMI and risk of surgical site infection (p < 0.001) and anastomotic leakage (p = 0.02). Higher BMI might also led to a reduced number of harvest lymph nodes for patients with colorectal cancer (p = 0.02). The heterogeneity test identified no significant cross-study heterogeneity, and the results of cumulative meta-analysis, sensitivity analysis, and the publication bias test verified the reliability of our study.

LIMITATIONS

Most studies included were retrospectively designed.

CONCLUSIONS

Body mass index is a practical and valuable measurement for the prediction of the perioperative outcome of laparoscopic colorectal surgery. Higher BMI is associated with worse perioperative outcome. More accurate conclusions, with more precise cutoff values, can be achieved by future well-designed prospective investigations.

The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

AIM

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

METHOD

A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined.

RESULTS

Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time.

CONCLUSION

Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.

Safety and feasibility of laparoscopic colo-rectal surgery for cancer at a tertiary center in a developing country: Egypt as an example

BACKGROUND

Laparoscopic colectomy has been shown to have significant short- and long-term benefits compared to open approach. The incorporation of laparoscopy in developing countries is challenging, due to the high costs of equipment and lack of expertise. The aim of this study was to evaluate the safety and feasibility of laparoscopic colorectal surgery for cancer that could be performed in developing countries under different circumstances in developed countries.

METHODS

Thirty-seven patients (23 males and 14 females) with colorectal cancer with a median age of 46 years (39-72) have been enrolled for laparoscopic colo-rectal surgery in a tertiary center in Egypt (South Egypt Cancer Institute) with the trend of reuse of some disposable laparoscopic instruments.

RESULTS

The median operative time was 130 min (95-195 min). The median estimated blood loss was 70 ml (30-90 ml). No major intra-operative complications have been encountered. Two cases (5.5%) have been converted because of local advancement (one case) and bleeding with unavailability of vessel sealing device at that time (one case). The median time for passing flatus after surgery was 36 h (12-72 h). The median hospital stay was 4.8 days (4-7 days). The peri-operative period passed without events. Pathologic outcome revealed that the median number of retrieved lymph nodes was 14 (range 9-23 lymph node) and all cases had free surgical margin.

CONCLUSION

Laparoscopic colorectal surgery for cancer in developing countries could be safe and feasible. Safe reuse of disposable expensive parts of some laparoscopic instruments could help in propagation of this technique in developing countries.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients

BACKGROUND

Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear.

STUDY DESIGN

Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups.

RESULTS

Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70).

CONCLUSION

Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

Three ports laparoscopic resection for colorectal cancer: a step on refining of reduced port surgery

Background. Reduced port surgery (RPS) is becoming increasingly popular for some surgeries. However, the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique (10 mm umbilical port plus another two ports of either 5 or 10 mm) for twenty-four cases of colorectal cancer as a step for refining of RPS. Results. The mean estimated blood loss was 70 mL (40–90 mL). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 5 days (4–7 days). The perioperative period passed without events. All cases had free surgical margins. The mean number of retrieved lymph nodes was 14 lymph nodes (5–23). Conclusion. Three ports laparoscopy assisted colorectal surgeries looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery. It's a step on the way of refining of reduced port surgery.

Surgical outcome of laparoscopic colectomy for colorectal cancer in obese patients: A comparative study with open colectomy

The aim of the present study was to assess the short-term outcome and survival time of 166 obese patients who received laparoscopic and open colectomy for colorectal cancer (CRC) between January 2007 and December 2012. All 166 patients included in the study had a BMI >28. Laparoscopic or open colectomy procedures were performed on 64 and 102 patients, respectively. The short-term outcome and post-operative survival rates were compared. The patient characteristics were similar between the two groups. Laparoscopic colectomy correlated with an increased duration of surgery compared with open colectomy (183 vs. 167 min, respectively; P<0.05) but intraoperative blood loss was decreased (168 vs. 188 ml, respectively; P<0.05). Hospitalization costs were slightly higher following the laparoscopic procedure compared with open surgery, but this was affordable for the majority of patients (¥56,484 vs. ¥56,161, respectively; P<0.05). The incidence of wound infection (17 vs. 31%; P<0.05) and abdominal abscess rates (6 vs. 18%; P<0.05) were reduced in the laparoscopic group compared with the open group. Pathological characteristics were identified to be similar and no significant differences were identified in overall (log-rank test; P=0.85) and disease-free (log-rank test; P=0.85) survival between the two types of surgery (log-rank test; P=0.76). The current retrospective study demonstrated an improved short-term outcome in laparoscopic colectomy for CRC patients with a BMI >28 compared with patients who underwent the open procedure. Laparoscopic colectomy is technically and oncologically safe and must be popularized in obese CRC patients.

Gravity line strategy may reduce risks of intraoperative injury during laparoscopic surgery

BACKGROUND

"Tilt" of surgical view was commonly shown on the monitor due to unintentional rotation of camera along its long axis by camera driver. Surgeons may be influenced on identification of anatomical structures by the tilt vision. We aimed to analyze the surgical records and videos of laparoscopic surgery, and to reveal the correlation between intraoperative complications and tilt view.

METHODS

A series of 425 consecutive patients who received laparoscopic low anterior resection and abdominoperineal resection were studied, and 398 surgery videos were reviewed. Still pictures showing intraoperative injury were selected. A method was established to measure tilt angle in the still pictures according to the reference line based on several anatomic landmarks. The patients were grouped with two methods according to different study purposes. Incidence of intraoperative complication and tilt angle were calculated, and statistical analysis was performed.

RESULTS

The incidence of intraoperative complications was 8.3%. Tilt of the surgical field at different degrees (<15°, 15°-30° and >30°) was found in a relatively high rate in these surgery videos (31.4%). Compared with controls, comparatively bigger tilt angles were found in all cases of complication group. It is interesting to note that intraoperative complications happened more often when the tilt angle was in the range of 15°-30° (72.7%) than >30° (18.2%). We also noted a high incidence of complication (72.7%), while tilt angle was over 15° (26%) in the first 100 cases; comparatively a steady declining low rate of complication occurrence (5-7%) and also tilt angle over 15° (9-11%) were noted in the later 298 cases.

CONCLUSIONS

Rotation of camera is common during laparoscopic procedures. The tilt view increased the risk of laparoscopic procedures. Tilt angle at 15-30° is the most dangerous rotation for laparoscopic surgeries. Therefore, we propose the "Gravity Line Strategy" principle as one of the basic operating criteria to correct the tilt angle.

Laparoscopic colectomy reduces morbidity and mortality in obese patients

BACKGROUND

Obesity is a growing epidemic in the US and increases the difficulty of laparoscopic surgery. Randomized, controlled trials of laparoscopic vs. open colectomy have shown equivalence but often exclude obese patients thus not answering whether obese patients may specifically benefit from laparoscopy. We hypothesized that obese patients would benefit from use of laparoscopy for colectomy.

METHODS

We used the National Surgical Quality Improvement Program database from 2005 to 2009 and chose elective laparoscopic and open segmental colectomy and ileocecal resections. We compared patients' demographics, comorbidities, and outcomes. We used multivariate models to assess for predictors of complications in obese patients. These models included demographics, comorbidities, and outcomes.

RESULTS

35,998 patients were identified who underwent elective colectomy with primary anastomosis. Forty-four percent of the included cases were laparoscopic and 31 % of patients had a BMI greater than 30 (obese). Obese patients were more likely to have diabetes, hypertension, prior percutaneous coronary intervention, and dyspnea on exertion. We constructed a new variable called any complication that included all complications except 30-day mortality. In our multivariate analysis, laparoscopic approach in obese patients independently decreased the relative risk of superficial (odds ratio (OR) 0.72, 95 % confidence interval (CI) 0.63-0.82) and deep (OR 0.44, CI 0.31-0.61) surgical site infections, intra-abdominal infection (OR 0.61, CI 0.49-0.78), dehiscence (OR 0.50, CI 0.35-0.69), pneumonia (OR 0.60, CI 0.44-0.81), failure to wean from the ventilator (OR 0.64, CI 0.47-0.87), renal failure (OR 0.58, CI 0.35-0.96), urinary tract infection (OR 0.62, CI 0.49-0.79), sepsis (OR 0.53, CI 0.43-0.66), septic shock (OR 0.65, CI 0.47-0.90), any complication (OR 0.61, CI 0.55-0.67) and 30-day mortality (OR 0.56, CI 0.31-0.98).

CONCLUSIONS

Due to the significant decrease in the risk of morbidity and mortality, laparoscopic colectomy should be offered to obese patients whenever feasible.

Complications following colon rectal surgery in the obese patient

It is well recognized that obesity contributes to multiple co-morbidities, and it would seem intuitive that obese patients experience an increase in post-operative complications after colorectal surgery. Overall, the data examining postoperative morbidity and mortality in the obese colorectal patient is inconsistent. Studies have shown a trend for obese patients have a higher post-operative risk of pulmonary embolism, atelectasis, cardiac complications, and thromboembolic disease. However, even with multiple large trials concluding this, there are also many studies showing no difference. The literature has shown that using laparoscopic techniques is safe and feasible, but there is a higher rate of conversion to open, and longer operative times. In addition, obese patients might have a higher leak rate for distal anastomosis as compared with normal weight patients. These patients also have a higher post-operative rate of stomal complications and fascial dehiscense. In reviewing the literature, at best, the complication rate in obese patients is the same as non-obese patients after colorectal surgery, but there are significant trends that suggest a negative effect of obesity after colorectal surgery.

Single-incision laparoscopic total colectomy

BACKGROUND AND OBJECTIVES

To present our experience with a single-incision laparoscopic total colectomy, along with a literature review of all published cases on single-incision laparoscopic total colectomy.

METHODS

A total of 22 cases were published between 2010 and 2011, with our patient being case 23. These procedures were performed in the United States and United Kingdom. Surgical procedures included total colectomy with end ileostomy, proctocolectomy with ileorectal anastomosis, and total proctocolectomy with ileopouch-anal anastomosis. Intraoperative and postoperative data are analyzed.

RESULTS

Twenty-two of the 23 cases were performed for benign cases including Crohns, ulcerative colitis, and familial adenomatous polyposis. One case was performed for adenocarcinoma of the cecum. The mean age was 35.3 years (range, 13 to 64), the mean body mass index was 20.1 (range, 19 to 25), mean operative time was 175.9 minutes (range, 139 to 216), mean blood loss was 95.3mL (range, 59 to 200), mean incision length was 2.61cm (range, 2 to 3). Average follow-up was 4.6 months with 2 reported complications.

CONCLUSIONS

Single-incision laparoscopic total colectomy is feasible and safe in the hands of an experienced surgeon. It has been performed for both benign and malignant cases. It is comparable to the conventional multi-port laparoscopic total colectomy.

The impact of obesity on learning laparoscopic surgery for colon cancer

OBJECTIVE

This study evaluated the impact of obesity on learning to perform laparoscopic surgery for colon cancer.

SUBJECTS AND METHODS

We compared the outcomes for 72 patients with colon cancer treated by a single surgeon between June 2005 and July 2008. The first 36 patients who underwent surgery were considered to be during the "early period," and the other 36 patients who underwent surgery as the "late period," and the patients with a body mass index (BMI) ≥25 kg/m(2) were defined as being obese.

RESULTS

During the early period, the tumor stages of obese patients were less advanced than those of nonobese patients, whereas the length of the operation, surgical blood loss, and wound diameter of obese patients were worse than those of nonobese patients. Furthermore, the tumor stages in the obese patients during the late period were more advanced than those in obese patients during the early period, whereas the length of the operation and number of dissected lymph nodes in the obese patients during the late period were better than those in obese patients during the early period.

CONCLUSIONS

We demonstrated that the differences of the surgical outcomes between obese and nonobese patients undergoing laparoscopic colon resection decreased as the surgeon's experience increased.

Outcome of laparoscopic colorectal surgery in obese and nonobese patients: a meta-analysis

BACKGROUND

Obese patients are generally believed to be at increased risk for surgery compared with those who are not obese. A meta-analysis was performed to assess the outcomes of laparoscopic colorectal surgery in obese and nonobese patients.

METHODS

A systematic literature search from inception to June 2011 was performed. Pooled odds ratios (OR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using the fixed effects model or random effects model.

RESULTS

Eight observational studies identified and matched the selection criteria. Conversion rates (OR: 2.31, 95% CI: 1.74-3.08), operating time (WMD: 15.33, 95% CI: 1.81-28.85), and postoperative morbidity (OR: 2.11; 95% CI: 1.3-3.42) were all significantly increased in the obese group. Length of hospital stay and mortality were similar in both groups. For patients with cancer, there was no difference between groups for the number of harvested nodes and length of specimen.

CONCLUSIONS

Obesity is associated with increased conversion rate, operating time, and postoperative morbidity of laparoscopic colorectal surgery but does not affect surgical safety or oncological security.