Laparoscopic colorectal surgery modifies risk factors for postoperative morbidity

Early non compliance to enhanced recovery pathway might be an alert for underlying complications following colon surgery

PURPOSE

Early non compliance to postoperative ERAS pathway has been reported in 20-30% of patients who underwent elective colon surgery. The aim of the present study is to investigate the possible relationship between early non compliance and postoperative complications.

METHODS

We reviewed a prospective database including 1391 consecutively collected patients undergoing elective colon surgery in 22 Italian hospitals between January 2017 and June 2020. Early compliance to ERAS protocol was assessed on postoperative day (POD) 2. Failure of oral feeding, urinary catheter removal, intravenous fluids stop, and adequate mobilization were indicators of non compliance. Postoperative follow-up was carried out for 30 days after hospital discharge. The association among early postoperative ERAS compliance and the occurrence of complications was assessed with uni- and multivariate analysis.

RESULTS

A total of 1089 (78.3%) patients had malignancy and minimally invasive surgery was successfully performed in 1174 (84.3%) patients. Postoperative morbidity occurred in 403 (29.0%) patients. At multivariate analysis, male gender, open surgery, and each of the four non compliance indicators on POD 2 were significantly associated to postoperative complications. Morbidity progressively increased from 16.8% in patients with full compliance to ERAS protocol to 47.2% in patients with two non compliance indicators and 69.2% in patients with all four indicators (p < 0.001).

CONCLUSIONS

Early non compliance to ERAS protocol was significantly associated with postoperative morbidity.

Clinical Validation of the Comprehensive Complication Index in Colon Cancer Surgery

(1) Introduction: To date, the sensitivity of the Comprehensive Complication Index (CCI) in a homogeneous cohort of colonic resections for oncologic purposes has not been reported. The present study aims to compare the CCI with the conventional Clavien-Dindo classification (CDC) in colon cancer patients. (2) Methods: The clinical data of patients submitted to an elective colectomy for adenocarcinoma were retrieved from a prospectively maintained database. Postoperative complications and length of stay were reviewed, and CDC and CCI scores were calculated for each patient. The association of the CCI and the CDC with the length of stay, prolongation of stay and readmission rate were assessed and compared. (3) Results: The overall postoperative morbidity was 26.9%. In particular, 157 (20.4%) patients had more than one complication. A strong correlation between the two scoring systems was observed (r = 99.4%; 95%CI: 99.3-99.5%). In multivariate analysis, CCI had a higher predictive ability for all endpoints. Regarding subgroup analysis, the difference between the CCI and CDC was progressively increased when evaluating outcome measures in complicated and multi-complicated patients. (4) Conclusion: Both scoring systems adequately report the overall burden of postoperative complications. The CCI showed a greater ability than the CDC to predict hospital stay, particularly in patients with multiple postoperative complications.

Postoperative Infection after Colorectal Surgery: Subanalysis of Data from the 2015 Japan Postoperative Infectious Complications Survey

BACKGROUND

Most surveillance programs for postoperative infection focus on surgical site infections (SSI). However, postoperative remote infections are of emerging clinical importance. Using data from a multicenter survey administered to patients who underwent gastrointestinal surgery, we investigated the incidence of SSI and remote infection after colorectal surgery.

METHODS

From September 2015 through March 2016, 1,724 patients underwent colorectal surgery in 28 affiliated centers in Japan. We retrospectively recorded patient age, sex, surgical site, surgical approach, wound classification, performance status at discharge, and postoperative infection status.

RESULTS

Postoperative infection was noted in 236 (13.7%) patients; 150 and 86 patients underwent colon and rectal surgeries, respectively (incidence of postoperative infection: 13.7% and 14.8%). The incidence of postoperative infection was significantly lower after laparoscopic surgery than after open surgery, in colon and rectal surgery (p < 0.001). Among patients with postoperative infections, 211 (89.4%) had a single infection and 25 (10.6%) had multiple infections. Among patients with a single postoperative infection, SSI and remote infection occurred in 143 (60.6%) and 68 (28.8%) patients, respectively. The most common multiple postoperative infections were "incisional and organ/space SSIs" and "organ/space SSI and bacteremia of unknown origin" (n = 3 each).

CONCLUSIONS

This study revealed the prevalence distributions for postoperative SSI and remote infections. Because of the substantial effect of remote infections on patient quality of life and the associated social burden, prospective periodic surveillance for SSI and remote infection is necessary for careful evaluation and prevention.

Rate of conversion to an open procedure is reduced in patients undergoing robotic colorectal surgery: A single-institution experience

Background

Robotic-assisted surgery is becoming increasingly used in colorectal operations. It has many advantages over laparoscopic surgery including three-dimensional viewing, motion scaling, improved dexterity and ergonomics as well as increased precision. However, there are also disadvantages to robotic surgery such as lack of tactile feedback, cost as well as limitations on multi-quadrant surgeries. The purpose of this study was to compare the rate of conversion to an open surgery in patients undergoing robotic-assisted colorectal surgery and traditional laparoscopic surgery.

Methods

Patients undergoing minimally invasive colorectal surgery for neoplastic and dysplastic disease from 2009 to 2016 were identified and examined retrospectively. The statistical software SAS, manufactured by SAS Institute, Cary, North Carolina. Continuous variables were analysed using analysis of variance test. Chi-square test was used to analyse categorical variables. P <0.05 was considered statistically significant.

Results

Two hundred and thirty-five patients were identified that underwent minimally invasive colorectal surgery. One hundred and sixty-four underwent laparoscopic resection and 71 underwent robotic-assisted resection. There was no statistical difference in gender or race between the two groups (both P > 0.05). Patients that underwent robotic-assisted resection were slightly younger than patients that underwent laparoscopic resection (61.6 years vs. 65.6 years; P= 0.02). When examining conversion to an open procedure, patients that underwent robotic-assisted resection had a significantly lower chance of conversion than did the patients undergoing a laparoscopic approach (11.27% vs. 29.78%; P= 0.0018).

Conclusion

Conversion rates from a minimally invasive procedure to an open procedure appear to be lower with robotic-assisted surgery compared to laparoscopic surgery.

Identification of core items in the enhanced recovery pathway

BACKGROUND & AIMS

The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection.

METHODS

This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint.

RESULTS

Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021).

CONCLUSIONS

In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

Enhanced recovery pathway in elderly patients undergoing colorectal surgery: is there an effect of increasing ages? Results from the perioperative Italian Society Registry

Previous studies reported that enhanced recovery pathway (ERP) is safe in elderly who did not require a specifically tailored protocol. In previous studies, elderly have been considered as a homogeneous cohort and the cut-off value to identify them was different. The aim of the present study is to assess the compliance to ERP and its impact on postoperative outcome in three subgroups of elderly patients with increasing ages. Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. 315 elderly patients undergoing elective colorectal resection were divided into three groups. Group 1: 71-75 years (n = 105), Group 2: 76-80 years (n = 117), Group 3: over 80 years (n = 93). Primary endpoints of the study were adherence to ERP and time to readiness for discharge (TRD). Compliance to ERP was similar in the three groups. No difference among groups was found for mortality, overall morbidity, major complications, reoperation rate and readmission rate. Median TRD and length of hospital stay (LOS) were progressively longer with increasing age (p = 0.018 and p = 0.078, respectively). Increasing age did not impact on adherence to ERP and postoperative morbidity, but delayed both TRD and LOS.

Laparoscopic versus open surgery for colorectal cancer in the older person: A systematic review

Background

Laparoscopic surgery is being increasingly offered to the older person.

Objective

To systematically review the literature regarding laparoscopic colorectal cancer surgery in older people and compare to younger adult populations.

Study selection

We included randomized controlled trials that compared open to laparoscopic colorectal cancer surgery. Older people were defined as being 65 years and above.

Outcome measures

Overall survival and post-operative morbidity and mortality. Secondary endpoints were length of hospital stay, wound recurrence, disease-free survival and conversion rate.

Results

Seven trials included older people, average age of approximately 70 years. Two reported data specific to older patients (over 70 years): The ALCCaS study reported reduced length of stay and short-term complication rates in the laparoscopic group when compared to open surgery (8 versus 10 days, and 36.7% versus 50.6% respectively) and the CLASICC study reported equivalent 5 year survival between arms and a reduction of 2 days length of stay following laparoscopic surgery in older people. In trials which considered data on older and younger participants all five trials reported comparable overall survival and showed comparable or reduced complication rates; two demonstrated significantly shorter length of stay following laparoscopic surgery compared to open surgery.

Conclusion

Large numbers of older people have been included in well-conducted, multi-centre, randomized controlled trials for laparoscopic and open colorectal cancer surgery. This systematic review suggests that age itself should not be a factor when considering the best surgical option for older patients.

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Seven well conducted randomised controlled trials of open versus laparoscopic colorectal cancer surgery have included older people.

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Age alone should not be a barrier to laparoscopic colorectal cancer surgery.

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The effect of comorbidity in older people undergoing laparoscopic surgery is less clear and warrants further study.

Short and long-term outcomes of laparoscopic colectomy in obese patients

AIM: To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases.

METHODS: A total of 98 obese (body mass index > 30 kg/m²) patients who underwent laparoscopic (LPS) right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy. Controls were selected to match for body mass index, site of primary disease, American Society of Anesthesiologists score, and year of surgery (± 3 year). The parameters analyzed included age, gender, comorbid conditions, American Society of Anaesthesiologists class, diagnosis, procedure, and duration of operation, operative blood loss, and amount of homologous blood transfused. Conversion rate, intra and postoperative complications as were as reoperation rate, 30 d and long-term morbidity rate were also analyzed. For continuous variables, the Student’s t test was used for normally distributed data the Mann-Whitney U test for non-normally distributed data. The Pearson’s χ² tests, or the Fisher exact test as appropriate, were used for proportions.

RESULTS: Conversion to open surgery was necessary in 13 of 98 patients (13.3%). In the LPS group, operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy (P = 0.03, P = 0.0001, respectively). Overall morbidity, anastomotic leak and readmission rate did not significantly differ between the two groups. A trend toward a reduction of wound complications was observed in the LPS when compared to open group (P = 0.09). In the LPS group, an earlier recovery of bowel function (P = 0.001) and a shorter length of stay (P = 0.03) were observed. After a median follow-up of 62 (range 12-132) mo 23 patients in the LPS group and 38 in the open group experienced long-term complications (LPS vs open, P = 0.03). Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one (P = 0.03).

CONCLUSION: Laparoscopic colectomy in obese patients is safe, does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Laparoscopic treatment of advanced colonic cancer: a case-matched control with open surgery

AIM

The safety, feasibility and oncological results of laparoscopic resection for advanced colon cancer were evaluated.

METHOD

Seventy consecutive patients with a histologically proven T4 colon cancer who underwent laparoscopic (LPS) right or left colectomy were matched for comorbidity on admission (American Society of Anesthesiologists score), tumour stage and grading with 70 patients who underwent open colectomy over a 10-year period. Short- and long-term outcome measures were evaluated.

RESULTS

The overall conversion rate was 7.1%. Less intra-operative blood loss (P = 0.01), a trend toward a longer operation time (P = 0.09) and a lower peri-operative blood transfusion rate (P = 0.06) were observed in the LPS group. A similar number of lymph nodes were retrieved (P = 0.37) and the R1 resection rate (P = 0.51) was no different in the two groups. The overall mortality rate was 1.4%. The overall morbidity rate was 21.4% (15/70 patients) in the LPS group and 27.5% (19/70 patients) in the open group (P = 0.42), with anastomotic leakage rates of 7.1% and 4.2% (P = 0.32). Length of stay was shorter after LPS (P = 0.009). Five-year overall survival rate (P = 0.18) and disease-free survival rate (P = 0.20) did not differ significantly between the two groups.

CONCLUSION

Laparoscopic treatment of T4 colon cancer is safe and feasible and provides a similar surgical and oncological outcome compared with the open technique.

Can postoperative complications be predicted by a routine CT scan on day 5? A study of 78 laparoscopic colorectal resections

BACKGROUND

Postoperative computed tomography (CT) scan patterns after colorectal resection are difficult to analyze for both clinicians and radiologists. This study aimed to assess the role of single CT scan on postoperative day 5 in predicting postoperative morbidity.

METHODS

From October 2007 to August 2009, 78 patients undergoing laparoscopic colorectal resection were enrolled in a research study involving a routine contrast-enhanced multi-detector CT scan on postoperative day 5. Two groups were defined: patients with intra-abdominal postoperative morbidity requiring specific management, i.e., surgical or radiological procedure, and/or antibiotic therapy ("complications" group), and patients with uneventful postoperative outcome ("uneventful" group). CT findings were compared between the two groups with Fisher's exact test or chi-square test.

RESULTS

Postoperative abdominal complications occurred in 16 patients (21 %). Of the CT findings on day 5, pneumonia, pulmonary embolism, portal or mesenteric thrombosis, operative area fat infiltration, peritoneal effusion, pneumoperitoneum, intra-abdominal collection, parietal inflammation or collection, and subcutaneous emphysema were observed in both groups without any significant difference. Only small bowel distension [25 % (4/16) in the "complications" group vs. 5 % (3/62) in the "uneventful" group; p = 0.029] and pleural effusion [81 % (13/16) vs. 48 % (30/62); p = 0.024, respectively] were observed significantly more often in the "complications" group.

CONCLUSIONS

This study suggested that abdominal complications cannot be predicted by a CT scan on day 5 after laparoscopic colorectal resection. Thus, it cannot be recommended for routine use.

Perioperative blood transfusion in cancer patients undergoing laparoscopic colorectal resection: risk factors and impact on survival

BACKGROUND

Perioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer.

METHODS

Data were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary.

RESULTS

Two hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I-III). Sixty-eight (33.8 %) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan-Meier overall survival analysis was significantly worse in patients who received blood transfusions (P = 0.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (P = 0.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (OR = 2.1, P = 0.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index.

CONCLUSIONS

Perioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.

Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger

BACKGROUND

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP).

METHODS

Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients.

RESULTS AND DISCUSSION

Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status.

CONCLUSIONS

Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

Anesthesia and perioperative management of colorectal surgical patients - specific issues (part 2)

Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.

Lymph node harvested in laparoscopic versus open colorectal cancer approaches: a meta-analysis

Increasing researches have reported the safety and efficacy of laparoscopic versus open approach for colorectal cancer resection; however, the number of lymph nodes harvested in the 2 approaches is still unclear. This meta-analysis is to compare the number of lymph node harvested in these 2 methods. We searched the PUBMED, the EMBASE, and the Cochrane Library up to July 1, 2011 for relevant studies. Twenty-four randomized controlled trials, comprising 6264 participants, met our criterion. We found no difference in the number of lymph nodes harvested in these 2 approaches (weighted mean difference=-0.25; 95% confidence interval, -0.57 to 0.08; P=0.542), as well as in subgroups of colon cancer and of rectal cancer. Our meta-analysis suggests that laparoscopic surgery could achieve the same effectiveness with open surgery in relation to lymph node harvested. Surgeons should pay appropriate attention on the excision of lymph nodes, which are associated with long-term benefits of patients.

Multivariate analysis of risk factors for pulmonary complications after hepatic resection

OBJECTIVE

To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy.

BACKGROUND

Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery.

METHODS

Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism.

RESULTS

Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8).

CONCLUSIONS

The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

An Evaluation of Alvimopan Use as Part of Perioperative Management of Patients Undergoing Laparoscopic Small and Large Bowel Resections

Objective

Delayed gastrointestinal (GI) recovery (postoperative ileus) is a risk for patients undergoing bowel resection (BR) and presents clinical challenges including prolonged hospital length of stay (LOS) and increased postoperative morbidity. Alvimopan, an oral, peripherally acting mu-opioid receptor antagonist, is the first therapy approved to accelerate GI recovery after BR. Published data have described alvimopan use in open BR. In contrast, this study focused on laparoscopic BR.

Methods

Historic data were retrospectively collected and alvimopan data were prospectively collected from 1 surgeon at our facility. Adults undergoing laparoscopic partial small or large BR with primary anastamosis scheduled to receive intravenous, opioid-based, patient-controlled analgesia were eligible. Pregnancy, opioid analgesic on the home medication reconciliation form, complete bowel obstruction, colostomy or ileostomy creation, and unplanned surgery were exclusion criteria. All patients were uniformly managed with a standardized accelerated postoperative care pathway to facilitate GI recovery. LOS, time to first bowel movement (BM), 30-day readmission rate, and the cost were evaluated. Data were analyzed using Pearson chi-square and independent samples t tests.

Results

Thirty-nine alvimopan and 56 historic cohort patients were included. Time to first BM was reduced by 1.2 days and LOS was reduced by 1.1 days (both P < .001) in the alvimopan cohort compared with control. Overall variable cost data were reduced by $1,368 in the alvimopan cohort. Readmission rates were low and comparable.

Conclusions

Laparoscopic surgery can decrease LOS compared with open BR; however, alvimopan use at our facility reduced LOS and time to BM while remaining cost-effective in this patient population.

Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery

BACKGROUND

Epidural analgesia is the mainstay of perioperative pain management in enhanced recovery programmes. This study compared short-term outcomes following epidural or intrathecal analgesia in patients undergoing elective laparoscopic colorectal surgery.

METHODS

A single-centre observational study was carried out in 175 consecutive patients who had elective laparoscopic colorectal surgery for benign or malignant disease within an enhanced recovery programme. Seventy-six patients received epidural analgesia and 99 had a single injection of intrathecal analgesia to provide perioperative pain control.

RESULTS

Patients who had intrathecal analgesia had a reduced median postoperative pain score compared with those receiving epidural analgesia (0 versus 3.5; P < 0.001), an earlier return to mobility (1 versus 4 days; P < 0.001) and a shorter hospital stay (4 versus 5 days; P < 0.001). Return to normal gut function and postoperative nausea and vomiting were similar in the two groups.

CONCLUSION

Intrathecal analgesia may have advantages over epidural analgesia in patients undergoing laparoscopic colorectal surgery.

Evaluations of laparoscopic proctocolectomy versus traditional technique in patients with rectal cancer

BACKGROUND

This was a retrospective study that evaluated the surgical outcomes of laparoscopic surgery (LS) for rectal cancer, in comparison with a case control series of open surgery (OS), during an 8-year period.

METHODOLOGY

Between October 1998 and December 2006, 203 patients with rectal malignancies underwent colectomy; 146 of them had colectomy with the traditional technique (OS), while 57 underwent resection of rectal cancer laparoscopically (LS). The LS group was compared with 60 patients from the OS group (selected from the 146 OS group patients), matched by size, sex, age, anatomical location of the tumor, type, extent of resection, and pathological stage. Data were obtained from patients' medical records. Statistical analysis was performed with the t test and chi-square test. All data are expressed as mean +/- standard error of the mean (SEM).

RESULTS

Mean age of the LS group was 63.7+/-12 years versus 69+/-12 years in the OS group. There were more men than women in both the laparoscopic (33 males, 24 females) and OS groups (35 men, 25 women). The mean follow-up period was 38 months and 78 months for LS and OS groups, respectively. The procedure included low anterior resection (43 in LS and 45 in OS), and 13 patients in both groups underwent abdominoperineal resection and 3 transanal resections (2 in OS and 1 in LS). Mean tumor size was 4.2+/-2.12cm in the LS versus 5.2+/-2.02cm in the OS group. Conversion to an open procedure occurred in 4 patients (6.7%), all in the first 20 cases. Postoperative complications developed in 28 patients (11.7%), 13 in the LS group and 15 in the OS group. Median operative time was longer, but median blood loss was significantly lower in the LS group. The length of hospital stay was significantly shorter for the LS group.

CONCLUSION

Laparoscopic surgery is feasible and safe for patients with rectal cancer and provides benefits during the postoperative period without increased morbidity or mortality.

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis

BACKGROUND

Restorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP.

SEARCH STRATEGY

We searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA.

SELECTION CRITERIA

All trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.

MAIN RESULTS

Eleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported.

AUTHORS' CONCLUSIONS

The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.

Wound infection after a laparoscopic resection for colorectal cancer

PURPOSE

The aim of this study was to investigate whether the wound infection (WI) rate in laparoscopic surgery (LS) for colorectal cancer is lower than that in open surgery (OS), and to evaluate the influence of perioperative intravenous antibiotic prophylaxis on the development of WI in LS.

METHODS

We performed a meta-analysis study comparing the WI rate in patients who underwent either OS or LS in randomized controlled trials (RCTs), with a relatively large number of registered patients. Moreover, a subgroup analysis of recently reported RCTs from Japan was performed, and 290 consecutive patients who underwent LS for colorectal cancer at our institution were evaluated for the influence of perioperative intravenous antibiotic prophylaxis on the development of WI.

RESULTS

The WI rate of the LS group was significantly lower than that of the OS group in a meta-analysis; however, no positive effect of the intra-and postoperative antibiotic prophylaxis on the development of WI was demonstrated.

CONCLUSIONS

Laparoscopic surgery for colorectal cancer is considered a surgical technique that has a lower incidence of WI in comparison to OS. Well-designed prospective, randomized controlled trials should therefore be conducted to evaluate whether intraoperative repeated dosing or postoperative repeated dosing is effective in reducing WI in LS.

Does the laparoscopic colorectal surgery learning curve adversely affect the results of colorectal cancer resection? A 3-year prospective study in a district general hospital

INTRODUCTION

Laparoscopic colorectal surgery is slowly being adopted across the UK. We present a 3-year prospective study of laparoscopic colorectal cancer resections in a district general hospital.

METHOD

Data relating to premorbid, operative and postoperative parameters were recorded for all patients undergoing laparoscopic, open, planned converted (laparoscopic assisted) and unplanned converted resections prospectively from April 2003 to April 2006.

RESULTS

A total of 238 colorectal resections were performed, 153 of which were for cancer. Of these 44 (29%) were open, 77 (50%) were laparoscopic and 32 (21%) were converted [26 (17%) planned and six (4%) unplanned]. Blood loss was less in the laparoscopic group compared with the open group (P = 0.02) as was intra-operative fluid replacement (P = 0.01). Time to requiring oral analgesia alone was shorter (P = 0.001) and bowel function returned earlier (P = 0.001) in the laparoscopic group. This is reflected in a trend towards a shorter hospital stay for the laparoscopic group compared with the open group (P = 0.049). The operating time of the laparoscopic group was not significantly longer (P = 0.38). The complication rate was similar between groups (P = 0.31) and the mortality in the laparoscopic group was 1.3%.

CONCLUSION

Changing from open to laparoscopic dissection for colorectal cancer is safe even during the initial learning curve. There are clear potential short-term benefits for patients and the technique can be introduced without penalties in terms of reduced surgical throughput.

Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?

BACKGROUND

Incisional hernias are a common postoperative complication with abdominal surgery. The major risk factors for their development include wound infection, obesity, and age. This study aimed to evaluate the impact of extraction-site location and technique on incisional hernia rates in laparoscopic colorectal surgery.

METHODS

A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. The study included only patients who had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up evaluation or underwent conversion to open procedure. For the 166 patients included in the study, the mean follow-up period was 20.2 +/- 14.4 months. Extraction-site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of no.1 Vicryl. Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with no. 1 Vicryl. Risk factors including wound infection, body mass index (BMI), age, and diabetes were analyzed.

RESULTS

The incisional hernia rate for the entire series was 7.8%. The incisional hernia rate was 17.6% for the midline group (n = 74) and 0% for the off-midline group (n = 92) (p = 0.0002, statistically significant). There was no statistically significant difference in age, BMI, diabetes, follow-up time, or wound infection rate between the two groups.

CONCLUSION

In this series, the midline extraction site resulted in a significantly higher incisional hernia rate statistically than the off-midline extraction sites. The authors therefore have adopted an off-midline blunt muscle-splitting extraction site when performing laparoscopic colorectal surgery.

Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?

BACKGROUND

Incisional hernias are a common postoperative complication with abdominal surgery. The major risk factors for their development include wound infection, obesity, and age. This study aimed to evaluate the impact of extraction-site location and technique on incisional hernia rates in laparoscopic colorectal surgery.

METHODS

A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. The study included only patients who had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up evaluation or underwent conversion to open procedure. For the 166 patients included in the study, the mean follow-up period was 20.2 +/- 14.4 months. Extraction-site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of no.1 Vicryl. Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with no. 1 Vicryl. Risk factors including wound infection, body mass index (BMI), age, and diabetes were analyzed.

RESULTS

The incisional hernia rate for the entire series was 7.8%. The incisional hernia rate was 17.6% for the midline group (n = 74) and 0% for the off-midline group (n = 92) (p = 0.0002, statistically significant). There was no statistically significant difference in age, BMI, diabetes, follow-up time, or wound infection rate between the two groups.

CONCLUSION

In this series, the midline extraction site resulted in a significantly higher incisional hernia rate statistically than the off-midline extraction sites. The authors therefore have adopted an off-midline blunt muscle-splitting extraction site when performing laparoscopic colorectal surgery.

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.

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.

Predictors and Outcome of Readmission after Laparoscopic Intestinal Surgery

BACKGROUND

Previous studies have failed to identify predictors of early readmission after major intestinal operations. The objectives of this study were to determine readmission rates, outcomes, and predictors of readmission for patients undergoing laparoscopic colon and rectal operations.

METHODS

Patients readmitted (PR) to the hospital within 30 days of discharge after laparoscopic colon and rectal operations were identified from a prospectively maintained database. The PR group was compared with patients that were not readmitted (NR). Outcomes and variables related to readmission were evaluated.

RESULTS

There were 820 consecutive elective laparoscopic colon and rectal operations performed over a 5-year period, with adequate follow-up data for 787 cases. Seventy-nine (10%) patients were readmitted. There was no difference in the age, sex, surgeon, or type of operation between the PR and NR groups. The most common causes for readmission were bowel obstruction (19%), ileus (18%), intra-abdominal abscess (14%), and anastomotic leak (9%). Overall mean (median) length of stay (LOS) for the index admission was 3.7 +/- 4.3 (3.0) days. Patients in the PR group had a trend toward a longer index admission LOS than the NR group (5.4 +/- 8.8 [3.0] versus 3.5 +/- 3.3 [3.0], p = 0.068). Univariate analysis demonstrated that patients with inflammatory bowel disease, pulmonary comorbidities, and steroid use were more likely to be readmitted. Multivariate analysis confirmed that inflammatory bowel disease and pulmonary comorbidity are independent risk factors for readmission.

CONCLUSIONS

Early readmission after laparoscopic colon and rectal operations is not associated with early discharge. Identification of specific patient characteristics indicating risk for early readmission may allow for selective changes in perioperative care or discharge criteria to avoid unexpected readmission.

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.

Dosis única preoperatoria de metronidazol más gentamicina para profilaxis antibiótica en cirugía colorrectal

BACKGROUND AND OBJECTIVE

To prove that a single-preoperative dose (SD) of metronidazole plus gentamicin guarantees the same clinical effectiveness than the same dose administered in a multiple-perioperative schedule (MD), with a reduction of the direct costs.

PATIENTS AND METHOD

A retrospective cohort study with patients undergoing elective colorectal surgery between 1995 and 2003 was designed. Patients in the cohort of cases received a SD of metronidazole 1500 mg plus gentamicin 240 mg between 1999 and 2003. Patients included in the cohort of controls received the same dose of antibiotics in a MD schedule between 1995 and 1997. Clinical effectiveness was evaluated as length of stay, mortality and rate of surgical-related infections. Economic analysis was performed using direct costs of therapy exclusively.

RESULTS

414 patients were included in the cohort of MD and 978 were included in the cohort of SD. Total length of stay (standard deviation) was 15.1 (16.2 days), with a significant reduction in the SD cohort versus the MD cohort: 14.0 (15.4) days versus 17.5 (17.8) days (p < 0.001). No differences in mortality (overall rate 3.2%) or surgical infection rate (overall rate 8.6%) between cohorts were found. SD schedule produces a 35% cost-reduction per procedure.

CONCLUSIONS

Attending the clinical effectiveness, no differences between SD and MD cohorts were found. Therefore, according to logistics advantages and costs reduction, the SD of antibiotic is considered the most efficient option.

Perforated diverticulitis managed by laparoscopic lavage

BACKGROUND

Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann's procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy. We present our early experience in managing perforated diverticulitis acutely by laparoscopic lavage and drainage.

METHODS

A retrospective review was conducted of all patients with surgically confirmed perforated diverticulitis. Details concerning the nature of presentation, operative findings, postoperative course and medium-term progress were investigated.

RESULTS

Fourteen patients with a mean age of 57.2 years were identified over a 3-year period. All patients presented with peritonitis and systemic sepsis. Ten patients had extraluminal gas on preoperative imaging. Laparoscopic lavage and drainage, without resection or stoma, was the initial management in all cases. Sigmoid diverticulitis was confirmed in all cases, complicated by Hinchey grade 3 purulent peritonitis in 10 patients, grade 2 contamination in 2 patients and grade 4 faeculent peritonitis in 2 patients. Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5-32 days). Three patients did not improve and underwent acute resection. Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks, which was carried out laparoscopically in all but one case.

CONCLUSION

Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis may be a promising alternative to more radical procedures, including the Hartmann's procedure. Acute resection should still be carried out in patients found to have faecal peritonitis or who fail to improve following lavage.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains controversial. However, laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME).

OBJECTIVES

To evaluate whether there are any relevant differences in safety and efficacy after elective LTME, for the resection of rectal cancer, compared with OTME.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Cochrane Central register of Controlled Trials (CENTRAL), and Current Contents from 1990 to December 2005. Searches were conducted using MESH terms: "laparoscopy", "minimally invasive","colorectal neoplasms". Furthermore we used the following text words: laparoscopy, surgical procedures, minimally invasive, rectal cancer, rectal carcinoma, rectal adenocarcinoma, rectal neoplasms, anterior resection, abdominoperineal resection, total mesorectal excision.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials and case series comparing LTME versus OTME. Furthermore case reports which describe LTME were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality. All relevant studies have been categorized according to the evidence they provide according to the guidelines for "Levels of Evidence and Grades of Recommendation" supplied by the "Oxford Centre for Evidence-based Medicine". Disagreements were solved by discussion.

MAIN RESULTS

80 studies were identified of which 48 studies, representing 4224 patients, met the inclusion criteria. Methodological quality of most of the included studies was poor; three studies were grade 1b (individual randomised trial), 12 grade 2b (individual cohort study), 5 grade 3b (individual case-control study) and 28 grade 4 (case-series). As only one RCT described primary outcome, 3-year and 5-year disease-free survival rates, no meta-analyses could be performed. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes were found. There is evidence that LTME results in less blood loss, quicker return to normal diet, less pain, less narcotic use and less immune response. It seems likely that LTME is associated with longer operative time and higher costs. No results of quality of life were reported.

AUTHORS' CONCLUSIONS

Based on evidence mainly from non-randomized studies, LTME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer. The long-term impact on oncological endpoints awaits the findings from large on-going randomized trials.

Laparoscopic versus open colorectal surgery: cost-benefit analysis in a single-center randomized trial

SUMMARY BACKGROUND DATA

Studies comparing the costs of colorectal resection by laparoscopic (LPS) and open approaches are small sized or not randomized. The main purpose of this study is to compare the hospital costs of LPS and open colorectal surgery in a large series of randomized patients.

METHODS

A total of 517 patients with colorectal disease were randomly assigned to LPS (n = 258) or open (n = 259) resection. The following costs were calculated: surgical instruments, operative room (OR) occupation, routine care, postoperative morbidity, and length of hospital stay (LOS). Follow-up for postoperative morbidity was carried out for 30 days after hospital discharge.

RESULTS

Operative time was 37 minutes longer in the LPS group. Overall morbidity rate was 18.2% (47 of 258) in the LPS versus 34.7% (90 of 259) in the open group (P = 0.0005). The mean LOS was 9.9 (2.6) days in the LPS group and 12.4 (3.9) days in the open group (P < 0.0001). The additional OR charge in the LPS group was 1171 per patient randomized (864 due to surgical instruments and 307 due to longer time). The saving in the LPS group was 1046 per patient randomized (401 due to shorter LOS and 645 due to the lower cost of postoperative complications). The net balance resulted in 125 extra cost per patient allocated to the LPS group.

CONCLUSIONS

The present cost-benefit analysis showed a slight additional cost in the LPS group. The better postoperative short-term outcome in patients receiving LPS had a key role to nearly balance the operative room charges due to laparoscopy.

Laparoscopic vs. open colectomies in octogenarians: a case-matched control study

PURPOSE

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 80 years old compared with open colectomy.

METHODS

Sixty-one patients undergoing laparoscopic colectomy for colorectal cancer were matched to 61 open colectomy patients for gender, age, year of surgery, site of cancer, and comorbidity on admission. Independence status on admission and at discharge from the hospital was also evaluated.

RESULTS

Mean (standard deviation) age was 82.3 (3.5) years in the laparoscopy group and 83.1 (3.3) years in the open group. Conversion rate was 6.1 percent. Operative time was 49 minutes longer in the laparoscopy group (P = 0.001). The overall mortality rate was 2.4 percent. The morbidity rate was 21.5 percent in the laparoscopy group and 31.1 percent in the open group (P = 0.30). Patients in the laparoscopy group had a faster recovery of bowel function (P = 0.01) and a significant reduction of the mean length of hospital stay (9.8 vs. 12.9 days for the open group, P = 0.001). Laparoscopy allowed a better preservation of postoperative independence status compared with the that of the open group (P = 0.02).

CONCLUSION

Laparoscopic colectomy for cancer in octogenarians is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.