Current attitudes in laparoscopic colorectal surgery

Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data

INTRODUCTION

Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database.

METHODS AND PROCEDURES

The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people).

RESULTS

Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001).

CONCLUSIONS

Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.

Impact of surgical indication on patient outcomes and compliance with enhanced recovery program for colorectal surgery: A Francophone multicenter retrospective analysis

BACKGROUND AND OBJECTIVE

The impact of surgical indication on compliance with enhanced recovery program (ERP) and on outcomes has never been assessed. This study aims to assess the impact of surgical indication (malignant vs benign) on postoperative outcomes and ERP compliance.

METHODS

A multicenter nationwide database was analyzed. Patients who underwent colorectal surgery for benign disease and those who underwent colorectal surgery for cancer were compared. Inclusion criteria were elective colorectal resection with anastomosis. ERP components, postoperative morbidity, and hospital length of hospital stay data were collected.

RESULTS

Among the 6472 patients registered in the database between October 2012 and June 2018, 4528 patients were included; 2647 in the malignant group and 1881 in the benign group. The ERP compliance over 70% was not different between groups. Postoperative morbidity rate was higher in the malignant group (22.5% vs 19.3%; P = .009) but not confirmed in multivariate analysis. Patients in the malignant group were more often readmitted after discharge, 6.6% vs 4.6% (P = .004). The mean LOS was 6.3 ± 5.0 days in the malignant group and 5.4 ± 4.7 days in the benign group (P < .001).

CONCLUSIONS

Indication for colorectal surgery did not significantly influence peri-operative management and postoperative major complications, in patients managed within an enhanced recovery program.

Selection Bias in Colorectal Surgery in a Non-Tertiary Hospital: Laparoscopic Versus Open Surgery

INTRODUCTION

Laparoscopy is used increasingly to treat malignant and benign colorectal surgical diseases. However, this practice is still not offered to all patients. Many barriers halt the widespread use of laparoscopic colorectal surgery. Both surgeon's and patient's factors contribute to limit a wider use of laparoscopy in colorectal surgery.

MATERIALS AND METHODS

We retrospectively analyzed 408 consecutive colorectal resections in a 4-year period, to find out if a selection bias exists in using laparotomy or laparoscopy for colorectal surgical diseases, and which factors are associated with a poor use of laparoscopy or to a preferred laparotomy.

RESULTS

In our practice, advanced disease, American Society of Anesthesiologist class III and IV, and emergency status are all patient-related factors associated with laparotomy. Surgeon's age more than 52 years and lack of laparoscopic training are surgeon-related factors that negatively affect the chance of being operated on with the laparoscopic technique.

CONCLUSIONS

An extensive laparoscopic colorectal training and a supporting environment, especially during the night shift, are needed to facilitate the use of laparoscopy in colorectal surgery avoiding a bias in selecting surgical candidates to one technique or another.

A critical appraisal of the cost effectiveness of laparoscopic colorectal surgery for oncological and non-oncological resections

The aim of this study was to critically appraise the cost effectiveness of the laparoscopic colorectal (LCRS) surgery using published randomised, control trials (RCTs). Published RCTs comparing the cost effectiveness of LCRS with conventional open surgery were selected from the search of standard electronic databases and the extracted data were analysed using the statistical software RevMan 5.3. Seven RCTs on 2197 patients reported the cost effectiveness of the LCRS. There was significant heterogeneity (τ ² = 161,772.25, χ ² = 166.69, df = 6, p = 0.00001, I ² = 96%) among included randomised, controlled trials. In the random effects model analysis (MD 320.37, 95% CI -38.21, 678.95, z = 1.75, p < 0.08), the LCRS was costing £320.37 more than open colorectal resection but it failed to reach the statistical significance indicating that LCRS is as much cost effective as the open approach. LCRS is a cost effective intervention and should be offered routinely to all patients requiring colorectal resections provided the resources and expertise are available.

Short-term outcomes of laparoscopically assisted surgery for rectal cancer following neoadjuvant chemoradiotherapy: a single-center experience

OBJECTIVE

The efficacy of laparoscopic treatment of rectal cancer remains unclear, and little is known about its effect on sphincter preservation. We compared short-term outcomes of laparoscopically assisted and open surgeries following neoadjuvant chemoradiotherapy (CRT) for mid and low rectal cancer.

METHODS

This study enrolled 137 patients with mid-low rectal cancer who underwent curative resection, 51 by laparoscopically assisted (Lap group) and 86 by conventional open (Open group) surgeries, following neoadjuvant CRT from July 2007 to July 2012. The clinical and surgical findings of the two groups of patients were prospectively collected and analyzed.

RESULTS

Three patients (5.9%) in the Lap group were converted to an open procedure. The mean operating times were similar in both groups. The Lap group had a significantly higher rate of sphincter preservation (62.7% versus 41.9%, P = 0.018) and significantly lower mean blood loss than the Open group. Mean times to first flatus, start of a normal diet, and overall postoperative hospitalization were longer for open surgery. The complication rate (11.8% versus 31.4%, P = 0.009) was significantly lower in the Lap group. Mean distal resection margin, involvement of the circumferential resection margin (2.0% versus 3.5%, P = 1.000), and mean lymph nodes harvested (12 versus 11; P = 0.242) were equivalent in the two groups.

CONCLUSIONS

Laparoscopically assisted surgery following neoadjuvant CRT is safe for patients with rectal cancer and provides favorable short-term benefits but without compromising oncologic outcomes. This sphincter-preserving procedure may be a treatment of choice for patients with lower rectal cancer.

Utilization of laparoscopic colectomy in the United States before and after the clinical outcomes of surgical therapy study group trial

OBJECTIVE

To evaluate the utilization of laparoscopic colectomy (LC) in the United States before and after prospective data supported its use for the treatment of colon cancer.

METHODS

The Nationwide Inpatient Sample 2001-2003 [before Clinical Outcomes of Surgical Therapy (COST)] and 2005-2007 (after COST) was queried for elective colectomies for both benign and malignant disease. The COST trial was published in 2004; therefore, 2004 data were excluded. Univariate analyses including patient-specific, hospital-specific, and outcome variables were performed. Multivariate logistic regression models and subset analyses were used to evaluate these variables and operative approach by time frame.

RESULTS

The query yielded 741,817 elective colectomies (684,969 open and 56,848 laparoscopic). The percentage of elective colectomies performed laparoscopically has increased over time. Laparoscopic colectomy for benign disease increased from 6.2% in 2001-2003 to 11.8% in 2005-2007, while those for colon cancer have increased by a larger percentage, 2.3% to 8.9%. In a multivariate model of patients with colon cancer, the odds ratio (OR) for having a laparoscopic approach after COST was 4.55 (confidence interval 3.81-5.44) compared with before COST. In contrast, for benign disease, the OR was 2.10 (confidence interval 1.79-2.46). Factors predictive of having a laparoscopic approach for cancer have changed very little over time: Patients are more likely to be male, insured, live in areas with the highest incomes, and undergo resection at urban teaching hospitals.

CONCLUSIONS

Within 3 years after publication of the COST trial, the use of laparoscopic resection for colon cancer approached that of benign disease. However, almost 90% of cases are still performed open and utilization remains influenced by socioeconomic factors.

Laparoscopic approaches to rectal cancer

Laparoscopic colectomy has been proven oncologically equivalent to conventional surgery and is now generally agreed to offer patients a reduced length of stay, shorter recovery times, and improved cosmesis. In contrast, acceptance of laparoscopic proctectomy for rectal cancer has been much delayed and the enthusiasm of early studies has met considerable skepticism. For rectal cancer, it has been demonstrated that there is considerable variation between surgeons in disease-free survival and local pelvic recurrence after open proctectomy for rectal cancer. These differences are likely to be magnified when the technical challenge of laparoscopy is added to proctectomy. Minimally invasive approaches to rectal cancer need to demonstrate equivalent oncologic outcomes and maintenance or improvement in quality of life. This review will outline the current evidence for laparoscopy as a treatment option for patients with rectal cancer, emphasize the need for standardized approaches among multidisciplinary teams, and highlight the technical details of different laparoscopic operations for rectal cancer.

Review of available methods of simulation training to facilitate surgical education

The old paradigm of "see one, do one, teach one" has now changed to "see several, learn the skills and simulation, do one, teach one." Modern medicine over the past 30 years has undergone significant revolutions from earlier models made possible by significant technological advances. Scientific and technological progress has made these advances possible not only by increasing the complexity of procedures, but also by increasing the ability to have complex methods of training to perform these sophisticated procedures. Simulators in training labs have been much more embraced outside the operating room, with advanced cardiac life support using hands-on models (CPR "dummy") as well as a fusion with computer-based testing for examinations ranging from the United States medical licensure exam to the examinations administered by the American Board of Surgery and the American Board of Colon and Rectal Surgery. Thus, the development of training methods that test both technical skills and clinical acumen may be essential to help achieve both safety and financial goals.

Laparoscopic surgery for inflammatory bowel disease: does weight matter?

BACKGROUND

Recent studies have shown improved outcomes after laparoscopic colorectal surgery compared with laparotomy for surgery for both benign and malignant colorectal diseases, including inflammatory bowel disease (IBD). This study was designed to evaluate the results of laparoscopic colorectal resections in normal weight patients compared with overweight and obese patients with IBD.

METHODS

A retrospective analysis of a prospectively acquired institutional review board-approved surgical database was performed. All consecutive patients with IBD who underwent laparoscopy from January 1, 2000 to April 30, 2008 were reviewed. BMI, age, gender, comorbidities, ASA classification, and surgical- and disease-related variables, including 60-day postoperative complications, were reviewed. Chi-square, Mann-Whitney U test, and Student's t test were used for statistical analysis.

RESULTS

A total of 261 patients with IBD underwent laparoscopy: 48 were excluded and 213 were analyzed. Group I comprised 127 normal-weight patients (body mass index (BMI), 18.5-24.9 kg/m(2)), and group II included 67 overweight patients (BMI, 25-29.9 kg/m(2)) and 19 obese patients (BMI >or= 30 kg/m(2)). Crohn's disease was diagnosed in 86 (67.7%) patients in group I and 52 (60.4%) in group II. Procedures performed included ileocolic resection in 56% of patients in each group. Total colectomy with or without proctectomy was undertaken in 39.4% in group I and 40.7% in group II. The conversion rate was 18% for group I and 22.09% for group II (p > 0.005; not significant). The most common reason for conversion was failure to progress due to adhesions or phlegmon. There were no differences in major postoperative complication rates (wound infection, abscess, anastomotic leakage, or small-bowel obstruction) or mean hospital stay (6.7, 6.8, respectively), and there was no mortality.

CONCLUSIONS

Patients with IBD who were overweight or obese and who underwent laparoscopic bowel resection had no significant differences in the rates of conversion, major postoperative complications, or length of stay when comparing to patients with normal BMI. Therefore, the benefits of laparoscopic bowel resection should not be denied to overweight or obese patients based strictly on their BMI.

Evolution of laparoscopic colorectal surgery in Brazil: results of 4744 patients from the national registry

BACKGROUND

Since its introduction, laparoscopic colorectal surgery has raised intense debate and controversies regarding its safety and effectiveness.

METHODS

This multicentric registry reports the experience of 28 Brazilian surgical teams specializing in laparoscopic colorectal surgery.

RESULTS

Between 1992 and 2007, 4744 patients (1994 men--42% and 2750 women--58%) were operated upon, with ages ranging from 13 to 94 years (average 57.5 y). Benign diseases were diagnosed in 2356 patients (49.6%). Most diseases were located in 50.7% of the left and sigmoid colon, 28.2% in the rectum and anal canal, 8.0% in the right colon, and diffuse 7.0%. There were 181 (3.8%) intraoperative complications (from 0% to 14%). There were 261 (5.5%) reported conversions to laparotomy (from 0% to 16.5%), mainly during the early experience (n=119 -59.8%). Postoperative complications were registered in 683 (14.5%) patients (from 5.0% to 50%). Mortality occurred in 43 patients (0.8%). Surgeons who performed less than 50 cases reported similar rates of intraoperative (4.2% vs. 3.8%; P=0.7), postoperative complications (20.8% vs. 14.3%; P=0.07), and mortality (1.0% vs. 0.9%; P=0.5), but the conversion rate was higher (10.4% vs. 5.4%; P=0.04). Two thousand three hundred and eighty-nine (50.4%) malignant tumors were operated upon, and histologic classification showed 2347 (98%) adenocarcinomas, 30 (0.6%) spinocelular carcinomas, and 12 (0.2%) other histologic types. Tumor recurrence rate was 16.3% among patients followed more than 1 year. After an average follow-up of 52 months, 19 (0.8%) parietal recurrences were reported, 18 of which were in port sites and 1 in a patient with disseminated disease. There was no incisional recurrence in the ports used to withdraw the pathologic specimen. Compared with other registries, there was a 75% increase in the number of groups performing laparoscopic colorectal surgery and a decrease in conversions (from 10.5% to 5.5%) and mortality (from 1.5% to 0.9%) rates.

CONCLUSIONS

(1) The number of patients operated upon increased expressively during the last years; (2) operative indications for benign and malignant diseases were similar, and diverticular disease of the colon comprised 40% of the benign ones; (3) conversion and mortality rates decreased over time; (4) surgeon's experience did not influence the complication rates, but was associated with a lower conversion; and (5) oncologic outcome expressed by recurrence rates showed results similar to those reported in conventional surgery.

Easy sphincterotomy in patients with Billroth II gastrectomy: a new technique

BACKGROUND/AIMS

ERCP and endoscopic sphincterotomy in patients with Billroth II gastrectomy are technically more difficult due to the reversed anatomy. We developed a new guidewire sphincterotome that includes two 15-mm non-isolated metal parts, one of which is located 12 cm from the distal tip and the other in the proximal end. The aim of this study was to evaluate the feasibility of and outcomes with the new sphincterotome for sphincterotomy in patients with Billroth II gastrectomy.

METHODS

Between January 2004 and March 2007, 11 patients with Billroth II gastrectomy underwent endoscopic sphincterotomy with the new guidewire sphincterotome. Procedures were initiated by deep cannulation of the bile duct with a standard catheter and guidewire sphincterotome. After cholangiography, the catheter was withdrawn with 0.5 to 1 cm of its tip outside the duodenoscope. The distal non-isolated part of the sphincterotome was placed in the papillary orifice. In order to reach the proper position, the duodenoscope's elevator was moved to the downward position, the up-down dial was turned slightly in the downward direction, and then the duodenoscope was pushed slightly forward. Finally, sphincterotomy was performed in the 6 o'clock direction.

RESULTS

Sphincterotomy with the new sphincterotome was successfully achieved in all patients without using protective pancreatic stents. Seven patients had common bile duct stones, two pancreatitis, one odditis, and another one persistent bile duct leakage. There were no sphincterotomyrelated complications or death during this study.

CONCLUSIONS

In this pilot study, endoscopic sphincterotomy with a new guidewire sphincterotome in patients with Billroth II gastrectomy was found to be clinically successful, concise, easy to perform, efficient, and reliable. However, further large comparative studies are needed for a definite conclusion.

Resultados do registro nacional brasileiro em vídeo-cirurgia colorretal - 2007

Este trabalho multicêntrico reúne a experiência de 28 equipes brasileiras em vídeo-cirurgia colorretal. No período de 1992 a 2007 foram operados 5259 pacientes, sendo excluídos 515 (9,8%) doentes devido a dados incompletos. Foram avaliados 4744 pacientes, sendo 1994 homens (41,4%) e 2750 mulheres (58,6%), cuja idade variou de 1 a 94 anos (média de 57,5 anos). Doenças benignas foram diagnosticadas em 2355 pacientes (49,6%). A maioria das afecções (50,7%) localizava-se no cólon esquerdo e sigmóide, 28,2% no reto e 0,3% no canal anal, 8,0% no cólon direito e 7,0% difusa. Ocorreram 29 óbitos (1,6%). Foram operados 2389 (50,4%) pacientes portados de tumores malignos, estando localizados no reto em 48,5%, cólon esquerdo e sigmóide 30,7%, cólon direito 16%, cólon transverso 3,2% e canal anal 0,6%. Os tipos histológicos foram 2347 (98%) adenocarcinomas, 30 (0,6%) carcinomas espinocelulares e outros tipos histológicos em 12 (0,2%) pacientes. A recidiva global foi de 15,3%. Houve 180 (3,8%) complicações intra-operatórias, sendo as mais comuns lesões vasculares de cavidade e lesões de alças intestinais, com incidência de 1%. Foram relatadas 261 (5,5 %) conversões para laparotomia, sendo a causa mais comum a dificuldade técnica em 1,4%. Complicações pós-operatórias foram registradas em 683 (14,5 %). Em período médio de 52 meses de seguimento houve 19 (0,8%) recidivas no local de inserção de trocártes. Não houve recidiva parietal em incisão utilizada para retirada da peça. CONCLUSÕES: 1) Nos últimos anos, a experiência brasileira em vídeo-cirurgia colorretal teve aumento expressivo; 2) As indicações operatórias para câncer e doenças benignas foram semelhantes, sendo que a doença diverticular representou 40 % das doenças benignas tratadas; 3) Os índices de morbi-mortalidade foram baixos e semelhantes aos relatados na literatura; 4) Os resultados oncológicos avaliados demonstram que as ressecções laparoscópicas determinam índices de recidiva parietal semelhantes aos encontrados em operações convencionais.

Comparison of laparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003-2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 +/- 6.4 vs 7.8 +/- 6.6 days) and in the benign laparoscopic groups (5.1 +/- 3.5 vs 7.2 +/- 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease.

[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 resection for colorectal cancer in Japan

The first laparoscopic surgery for colorectal cancer in Japan was reported in 1992. In the early phase, many cases were indicated for early cancer. The number of operations has been increasing year by year, and now even some advanced cases undergo laparoscopic surgery. According to questionnaires administered in 2003 by the Japan Society for Endoscopic Surgery, more than half of 3,892 cases were indicated for advanced cancer. In 2004, the 60th biannual meeting of the Japanese Society for Cancer of the Colon and Rectum took up "the current status of laparoscopic resection for colorectal cancer" as one of the main topics of the meeting, and conducted a questionnaire survey of the member's opinions to laparoscopic resection for colorectal cancer prior to the meeting. It was revealed that at least ninety institutes had already performed a laparoscopic resection for colorectal cancer. In order to evaluate the feasibility of laparoscopic resection for colorectal cancer, a randomized control study comparing laparoscopic and open resection of colorectal cancer was started in 2004. This study is scheduled to collect 818 cases. The characteristic of this study was to enroll only advanced cancer cases. The primary endpoint is the survival, while the secondary end points are disease-free survival, early postoperative course, adverse events and conversion to open surgery. As more surgeons perform laparoscopic colorectal surgery, the importance for education and credentialing has been discussed. The Japan Society for Endoscopic Surgery started a system to qualify the surgeon's technique for endoscopic and laparoscopic surgery in 2004. One hundred and three surgeons took the examination for laparoscopic colorectal surgery in 2004, and 43 passed.

Outcomes of laparoscopic Miles’ operation in very low rectal adenocarcinoma. Analysis of 32 cases

AIMS

Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers.

METHODS

The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival.

RESULTS

A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50.

CONCLUSIONS

The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Laparoscopic colorectal surgery in Great Britain and Ireland--where are we now?

OBJECTIVE

We aimed to gather information from the members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to assess trends in the current practice of laparoscopic colorectal surgery.

METHODS

A postal questionnaire survey of the members of ACPGBI.

RESULTS

The response rate was 37% (200/540). Only 45 surgeons currently perform laparoscopic colorectal work in Great Britain and Ireland mainly right hemicolectomy and laparoscopic stoma formation, of these about one third practiced laparoscopy for benign colorectal conditions only. The majority (68%) of surgeons had enough resources at their place of work, but further training seemed to be a major issue. Nearly 22% of surgeons had not had any formal training. Only 50% of surgeons trained their specialist registrars. The incidence of conversion rate was not different for benign or malignant conditions and also did not appear to be related to the duration of experience. Only four surgeons had noted port a site recurrence during the past 10 years. Seventy-five percent (150/200) felt that laparoscopic colorectal work could be carried out safely in a District General Hospital.

CONCLUSION

Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.

Impact of taurolidine on the growth of CC531 coloncarcinoma cells in vitro and in a laparoscopic animal model in rats

BACKGROUND

The object of this study was to examine the effect of taurolidine on intraabdominal tumor growth in a laparoscopic animal model. We tested the cytotoxic, antiadhesive, and anti-invasive effects of this substance on CC531 adenocarcinoma cells in vitro and in vivo using WAG rats.

METHODS

For in vitro experiments, Transwell dual chambers with polycarbonate filters coated with 100 microg/cm2 Matrigel were used to investigate the effects of 5, 10, and 20 microl of 2.0% taurolidine on the invasion of 1 x 10(5) CC531 adenocarcinoma cells. For the adhesion assays, tumor cells were applied onto microtiter plates coated with 5, 10, and 20 microl taurolidine and 0.9% NaCl solution for the control group subsequently. For in vivo experiments, 40 WAG rats were randomized into three therapy groups and one control group. All animals underwent laparoscopy and received 1 ml of CC531 adenocarcinoma cells (5 x 10(6) cells/ml) intraabdominally at the beginning of the procedure. According to the randomization, the rats were administered taurolidine with different concentrations or 1 ml of 0.9% NaCl solution for the control group. After 21 days, the animals were killed and the intraabdominal tumor weight was determined.

RESULTS

For the in vitro experiments, we found a moderate cytotoxicity and a significant inhibition of tumor cell adhesion and invasion (p < 0.01) by all taurolidine concentrations used in the assay. For in vivo experiments, the application of all concentrations of taurolidine significantly decreased the intraperitoneal tumor weight (p < 0.001).

CONCLUSION

Taurolidine significantly decreases adhesion and invasion of CC531 adenocarcinoma cells in vitro and significantly diminishes tumor growth in vivo. This may offer additional therapeutic options for laparoscopic surgery for colorectal cancer.

N/A

N/A

Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer

BACKGROUND

The Laparoscopic approach has been applied to colorectal surgery for many years; however, there are only a few reports on laparoscopic low and ultralow anterior resection with construction of coloanal anastomosis. This study compares open versus laparoscopic low and ultralow anterior resections, assesses the feasibility and efficacy of the laparoscopic approach of total mesorectal excision (TME) with anal sphincter preservation (ASP), and analyzes the short-term results of patients with low rectal cancer.

METHODS

We analyzed our experience via a prospective, randomized control trail. From June 2001 to September 2002, 171 patients with low rectal cancer underwent TME with ASP, 82 by the laparoscopic procedure and 89 by the open technique. The lowest margin of tumors was below peritoneal reflection and 1.5-8 cm above the dentate line (1.5-4.9 cm in 104 cases and 5-8 cm in 67 cases). The grouping was randomized.

RESULTS

Results of operation, postoperative recovery, and short-term oncological follow-up were compared between 82 laparoscopic procedures and 89 controls who underwent open surgery during the same period. In the laparoscopic group, 30 patients in whom low anterior resection was performed had the anastomosis below peritoneal reflection and more than 2 cm above the dentate line, 27 patients in whom ultralow anterior resection was performed had anastomotic height within 2 cm of the dentate line, and 25 patients in whom coloanal anastomosis was performed had the anastomosis at or below the dentate line. In the open group, the numbers were 35, 27, and 27, respectively. There was no statistical difference in operation time, administration of parenteral analgesics, start of food intake, and mortality rate between the two groups. However, blood loss was less, bowel function recovered earlier, and hospitalization time was shorter in the laparoscopic group.

CONCLUSION

Totally laparoscopic TME with ASP is feasible, and it is a minimally invasive technique with the benefits of much less blood loss during operation, earlier return of bowel function, and shorter hospitalization.

Patient-physician discordance about benefits and risks in gastroenterology decision-making

AIMS

To illustrate the characteristics of situations in gastroenterology when patients and physicians harbour different perspectives of medical costs and benefits, and how such different perspectives affect the outcome of medical decision-making.

METHODS

Two exemplary scenarios are presented, in which threshold analysis yields different results depending on the varying values assigned to identical medical events. The occurrence of varying values is subsequently phrased in economical terms of varying utility functions that characterize patient vs. physician behaviour.

RESULTS

Safety and therapy are the two major preferences that determine patient and physician utility functions. Patients and physicians make medical decisions based on two different utility functions. In comparison with their patients, gastroenterologists are more concerned with safety and inclined to spend more health care resources on safety than therapy because safety and the occurrence of medical complications affect their own professional status. In trying to maximize their own utility, gastroenterologists tend to spend more resources on safety than the patient him/herself might have spent given a free choice of management options.

CONCLUSIONS

In instances of potential complications associated with risky medical interventions, patients may receive less medical therapy in exchange for more procedural safety.

Laparoscopic vs open resection for the treatment of diverticular disease

INTRODUCTION

The aim of this study was to evaluate whether laparoscopic colon resection (LCR) offers any advantages over open colon resection (OCR) in the treatment of diverticular disease.

METHODS

Between 1992 and 2002, 95 patients underwent LCR and 80 patients underwent OCR for the treatment of diverticular disease. Demographics, details of operative procedure, outcome, and pathology were compared.

RESULTS

Patients in both groups were matched for age, sex, body mass index, history of previous abdominal operations, comorbidities, location of the disease, and presence of complications. LCR resulted in significantly less estimated blood loss and postoperative complications, shorter time to first bowel movement, and shorter length of stay than the OCR. There was no difference in operative time, intraoperative complications, mortality rates between groups.

CONCLUSIONS

LCR is a safe and effective approach for the treatment of patients with diverticular disease. It results in less estimated blood loss, shorter time to first bowel movement, less postoperative complications, and shorter length of hospital stay.

Surgeon experience with laparoscopic-assisted colorectal surgery in Washington State

PURPOSE

To describe the current practice and opinions held by surgeons performing colorectal surgery in Washington regarding laparoscopic colorectal surgery.

METHODS

After attempting to identify all surgeons with hospital privileges in colorectal surgery in Washington, a survey was sent to 303 surgeons. The survey asked about the surgeon's practice, volume of colon surgery in the preceding year, the number of laparoscopic colon resections ever performed, the surgeon's opinion on the future practice of laparoscopic colorectal surgery, and whether faced with the personal need to undergo colon resection at the present time, would the surgeon elect to have laparoscopic or open colon resection.

RESULTS

In all 170 surveys were returned; 154 returned surveys were from surgeons who had performed at least one colon resection in the preceding year; 53 (34%) respondents had experience with fewer than 20 laparoscopic resections and 83 (55%) have never performed laparoscopic-assisted colectomy (LAC). Only 4 (3%) surgeons had performed more than 50 laparoscopic colon resections. Forty-five percent of respondents indicated that they would currently seek a laparoscopic resection for themselves to treat either a benign condition or an incurable malignancy, and 84% of respondents indicated they would have an open colectomy for a curable malignancy.

CONCLUSIONS

The majority of surgeons performing colorectal resections in Washington have limited experience with LAC. Surgeon opinion regarding the role of laparoscopic colorectal surgery in clinical practice is mixed. We suggest a model for proctoring of LAC for surgeons interested in implementing laparoscopic colorectal resection into their practice.