Laparoscopic right colectomy: Miles away or just around the corner?

Surgical Resection for Crohn's and Cancer: A Comparison of Disease-Specific Risk Factors and Outcomes

BACKGROUND AND OBJECTIVES

The goal of this study was to compare disease-specific risk factors and 30-day outcomes between patients with Crohn's disease (CD) and colon cancer (CC) undergoing right-sided surgical resection.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP®) was interrogated to extract all patients ≥18 years undergoing elective right-sided resection for CD versus CC. Independent risk factors for surgical complications were identified through multivariable logistic regression for both groups. In a second step, surgical and medical 30-day morbidity was compared after risk adjustment.

RESULTS

The cohort consisted of 17,516 patients, of which 2,899 (16.6%) underwent surgery for CD versus 14,617 (83.4%) for CC. Independent risk factors for surgical complications in patients with CD were male gender, African American race, ASA score (III or IV), active smoking, prolonged surgery, and preoperative anemia. Independent risk factors for surgical complications in the cancer group were age ≥70 years, male gender, ASA score (III or IV), respiratory and cardiovascular comorbidities, and preoperative hypoalbuminemia (<3.5 g/dL). After risk adjustment, surgical complications (OR 1.25, p = 0.002), sepsis (OR 1.64, p = 0.012), and unplanned readmissions (OR 1.39, p = 0.004) were more common in patients with CD. Thirty-day mortality was higher in cancer patients (1.1 vs. 0.1%, p < 0.0001).

CONCLUSIONS

Patients with Crohn's disease were more prone to surgical complications and postoperative sepsis compared to the cancer group undergoing the same procedure. Careful evaluation and correction of disease-specific modifiable risk factors of patients with CD and CC, respectively, are important.

A standardised and simplified technique for laparoscopic resection of the splenic flexure

The splenic flexure is an uncommon location of colorectal cancer, being involved in 2%–3% of cases. The low chance of being engaged in resecting cancer of the splenic flexure can make it difficult for surgeons to build their learning curve and to achieve a reliable experience. As the majority of colectomies are still performed by low-volume surgeons, there is growing agreement that providing local services with adequate surgical education and training could be an effective strategy to improve outcomes and global health. Arming surgeons with simplified and easy-to-learn surgical techniques could be an important step of this strategy. A novel simplified technique for laparoscopic resection of the splenic flexure is presented, which combines laparoscopic mobilisation of the right colon with extracorporeal vascular ligation and bowel anastomosis.

Method of pedicle division during laparoscopic right hemicolectomy affects lymph node yield and short-term outcomes

BACKGROUND

Several ways of performing laparoscopic right hemicolectomy (RHC) have evolved. The vascular pedicle can be divided into extracorporeal (RHC-EC) or intracorporeal (RHC-IC). It is not known whether vessel ligation during RHC-EC is as central as during RHC-IC. We compare these approaches in terms of pathological and short-term clinical outcomes.

METHODS

Patients undergoing elective laparoscopic RHC in a single centre (July 2013-September 2016) were identified. Data collection included operative details, length of stay, complications, specimen parameters including number and involvement of lymph nodes and recurrence.

RESULTS

One hundred and sixty-nine patients were included (94 RHC-IC, 75 RHC-EC). For caecal and ascending colon cancers, mesocolic width was greater after RHC-IC than RHC-EC (7.9 cm versus 6.6 cm, P < 0.05), as was lymph node yield (19.5 versus 17.3, P < 0.05). There was no significant difference in length of colon resected, distal resection margin, number of positive nodes, proportion of node-positive tumours and R1 rate. Operative duration was higher for RHC-IC (163 min versus 91 min, P < 0.001), as was incidence of ileus (35% versus 15%, P < 0.05). Length of stay also tended to be higher (7.4 days versus 6.0 days, P = 0.19). There was no difference in disease recurrence (follow-up 12 months). Body mass index was positively correlated with lymph node yield for RHC-EC, but not for RHC-IC.

CONCLUSION

Lymph node yield after laparoscopic RHC is adequate, whether the vascular pedicle is taken intracorporeal or extracorporeal, supporting the use of both approaches. RHC-IC yields more lymph nodes and greater mesocolic width, but involves a longer operation and higher incidence of ileus.