Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery. We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups. The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively). LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.     

Laparoscopic surgery for rectal cancer: Review of published literature 2000–2009

We reviewed seven reports of laparoscopic low anterior resection (LAR) alone for rectal cancer and 18 reports of laparoscopic surgery, including LAR. We examined the length of surgery, blood loss during surgery, conversion rate to open surgery, incidence of anastomotic leakage, morbidity, mortality, and local recurrence, and the 5-year overall survival rates. The values were as follows (range): length of surgery, 107–540 min vs 23–780 min; blood loss, 0–600 ml vs 0–1800 ml; conversion to open surgery, 0%–14.0% vs 1.0%–21.9%; anastomotic leakage, 0%–23.0% vs 3.0%–17.0%; morbidity, 6.1%–38.6% vs 5.8%–40.0%; mortality, 0%–2.0% vs 05–5.8%; and local recurrence, 1.4%–6.8% vs 0.95%–20.8%, respectively, in the LAR alone vs laparoscopic surgery groups. The 5-year overall survival rates of patients with stage I, II, III, and IV disease were 92%–98%, 79%–81%, 67%–89%, and 0%–15%, respectively, in the LAR alone group versus 85.4%–100%, 61.7%–94.4%, 53.7%–78%, and 0%–44.6%, respectively, in the laparoscopic surgery group. Thus, we demonstrated the safety and efficacy of laparoscopic surgery for rectal cancer.     

Laparoscopic Colonic Resection for Rectosigmoid Colonic Tumours: A Retrospective Analysis and Comparison with Open Resection

Laparoscopic approach for treatment of colorectal malignancy is gaining acceptance gradually; however the benefits of laparoscopic surgery in colonic and rectal tumours is still open to debate. This study aims at a retrospective analysis of operative and short term outcome of patients with rectosigmoid tumours. A retrospective analysis of operative, postoperative and short-term outcome of 62 patients who underwent laparoscopic colorectal resection for cancer of rectosigmoid region were compared with a same number of parameters-matched patients who underwent open colorectal resection. Blood transfusion requirement was significantly more in the open group compared to the laparoscopy group (38.7% versus 6.4%, p = 0.001). ICU stay was less in the laparoscopy group (p = <0.05) and they were started on oral liquid diet earlier (p = 0.013). The number of the lymph nodes retrieved, positive distal margin and radial involvement were similar in both groups. The hospital stay was significantly shorter in laparoscopy group (8.4 versus 13.8 days, p < 0.05). Radical operation for rectosigmoid tumors is technically feasible with laparoscopic surgery. Laparoscopic approach is associated with less blood loss, transfusion and significantly less ICU stay. Laparoscopic group recovers early and needs less hospital stay     

Laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic outcomes and long-term survival

The study aimed to compare the oncologic outcomes and long-term survival of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for patients diagnosed with pancreatic ductal adenocarcinoma (PDAC). Substantial evidence demonstrated that LPD is technically safe and feasible with perioperative outcomes equivalent to that of OPD. However, for patients with malignancy, especially PDAC, the oncologic outcomes and long-term survival of patients who underwent LPD remains to be elucidated. Studies on LPD for the treatment of PDAC published before December 25, 2018 were searched online. The oncologic outcomes (e.g., numbers of lymph nodes retrieved, negative margin (R0) resection), and long-term survival (postoperative survival from 1 to 5 year) of LPD were compared to that of ODP. After screening 1507 studies, six comparative cohort studies, which reported the oncologic outcomes and long-term survival of patients with PDAC were included. No significant difference was found between LPD and OPD regarding lymph nodes harvested (OR 1.96, 95% CI − 1.17 to 5.09, p = 0.22), R0 rate (OR 1.44, 95% CI 1.00 to 2.06, p = 0.05), number of positive lymph nodes (OR − 0.44, 95% CI − 1.06 to 0.17, p = 0.16), rate of adjuvant treatment (OR 1.04, 95% CI 0.68 to 1.59, p = 0.86) and time to adjuvant treatment (OR − 6.21, 95% CI − 16.00 to 3.59, p = 0.21). LPD showed similar 1-year (OR 1.20, 95% CI 0.87 to 1.65, p = 0.28), and 2-year survival (OR 1.25, 95% CI 0.94 to 1.66, p = 0.13) to that of OPD. The 3-year (OR 1.50, 95% CI 1.12 to 2.02, p = 0.007), 4-year (OR 1.73, 95% CI 1.02 to 2.93, p = 0.04), and 5-year survival (OR 2.11, 95% CI 1.35 to 3.31, p = 0.001) were significantly longer in LPD group. For the treatment of PDAC, the oncologic outcomes of LPD were equivalent to that of OPD; LPD seemed promising regarding the postoperative long-term survival.     

腹腔镜与开腹直肠癌根治术肿瘤切除完整性及长期疗效的比较

目的：比较腹腔镜与开腹直肠癌根治术的肿瘤切除完整性及长期预后。方法回顾性分析2005年7月至2011年12月在上海第二军医大学长海医院肛肠外科行直肠癌根治手术的1184例患者的临床及随访资料,根据其手术方式分为腹腔镜手术组（腹腔镜组,104例）和开腹手术组（开腹组,1080例）,对两组患者的一般情况、术中清扫淋巴结数目、远切缘距离、吻合口相关并发症发生率、术后无病生存率及总生存率进行比较。结果腹腔镜组与开腹组患者的临床资料具有可比性,两组平均清扫淋巴结数目（15．5枚/例比14．4枚/例）、远切缘平均距离（2．5 cm比2．1 cm）及吻合口相关并发症发生率[1．9％（2/104）比1．9％（20/1080）]差异均无统计学意义（P＞0．05）;腹腔镜组术后3年和5年无病生存率分别为79．0％和69．3％,开腹组分别为78．0％和72．5％,差异无统计学意义（P＞0．05）;腹腔镜组术后3年和5年总体生存率分别为93．5％和81．2％,开腹组分别为87．6％和80．7％,差异亦无统计学意义（P＞0．05）。结论直肠癌腹腔镜手术肿瘤切除完整性和远期疗效与开腹手术相当。     

Impact of Residents on Safety Outcomes in Laparoscopic Cholecystectomy

New training programs face quality concern by faculty who believe resident involvement in operative management may lead to poorer outcomes. This study aims to understand the impact of resident surgeons on outcomes in a specific common surgical procedure. We obtained a retrospective review of 1216 laparoscopic cholecystectomy cases between June 2012 and June 2017 at a community teaching hospital. Data reviewed included patient demographics, operative time, length of stay, 30-day outcomes. An initial analysis comparing outcomes with/without resident participation was undertaken. A subset analysis comparing junior (PGY 1–2) and senior (PGY 3–5) groups was also performed. We found the resident group participated in higher-risk patient (ASA > 3, 47.5% vs 39.8%, p = 0.04 more acute disease (59.8% vs 37.5%, p < 0.0001) and emergent surgery (59.7% vs 37.5%, p < 0.0001). Resident involvement in severe cases was not a significant factor in the odds of morbidity, mortality, conversion rate or length of stay. Resident participation did increase the odds of having longer OR time (OR 12.54, 95% CI 7.74–17.34, p < 0.0001). Resident participation is associated with increased operative times but not complications. This study confirms resident participation in the operating room in difficult and challenging cases is safe.     

Perineal Healing and Survival After Anal Cancer Salvage Surgery: 10-Year Experience with Primary Perineal Reconstruction Using the Vertical Rectus Abdominis Myocutaneous (VRAM) Flap

Salvage surgery of recurrent or persistent anal cancer following radiotherapy is often followed by perineal wound complications. We examined survival and perineal wound complications in anal cancer salvage surgery during a 10-year period with primary perineal reconstruction predominantly performed using vertical rectus abdominis myocutaneous (VRAM) flap. Between 1997 and 2006, 49 patients underwent anal cancer salvage surgery. Of these, 48 had primary reconstruction with VRAM. Overall survival was computed by the Kaplan–Meier method and mortality rate ratios (MRRs) by Cox regression. One patient (2%) died within 30 days postoperatively. Postoperative complications necessitated reoperation in eight (16%) patients. We found no major perineal wound infections. Major perineal wound breakdown occurred in the only patient in whom VRAM was not used. Five-year survival was 61% [95% confidence interval (CI) 43–75%]. Free resection margins (R0) were obtained in 78% of patients, with 5-year survival of 75% (95% CI 53–87%). Involved margins, microscopically only (R1) or macroscopically (R2), strongly predicted an adverse outcome [age-adjusted 2-year MRRs (95% CI) R1 vs. R0 = 4.1 (0.7–23.6), R2 vs. R0 = 10.9 (2.2–54.2)]. We conclude that anal cancer salvage surgery can yield long-time survival but obtaining free margins is critical. A low rate of perineal complications is achievable by primary perineal reconstruction using VRAM flap.     

Palliative stoma creation: comparison of laparoscopic vs conventional procedures

Background  The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis. Materials and methods  In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared. Results  A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011). Conclusion  Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.     

Prognostic Factors and Adjuvant Chemoradiation Therapy After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Background  The aim of this study was to determine prognostic factors for survival after resection of pancreatic adenocarcinoma (PC) and to compare outcomes after surgery alone versus surgery plus adjuvant therapy. Methods  We performed a retrospective review of 219 patients who underwent pancreaticoduodenectomy for PC with curative intent between 1995 and 2007. Data were collected prospectively. Postoperative adjuvant chemoradiation therapy (CRT) consisted of fluorouracil or gemcitabine-based chemotherapy; the median radiation dose was 45 Gy. Results  The 3- and 5-year overall survival (OS) rates were 24.3% and 14.2%, respectively. Median OS was 14.0 months [95% confidence interval (CI), 12–16 months]. Patients with metastatic lymph nodes experienced improved median survival (16 vs 10 months; P < 0.001) and 3-year OS (3-year OS 28% vs 8%) after adjuvant CRT compared with those who had no CRT. Patients who underwent non-curative resection had the same effect (median OS, 13 vs 8 months; P = 0.037). Lymph node metastasis and non-curative resection showed no significance on multivariate analysis. Poor differentiation [risk ratio (RR) = 2.10; P < 0.001] and tumor size >3 cm (RR = 1.57; P = 0.018) were found to be adverse prognostic factors; adjuvant CRT had borderline significance (RR = 0.70; P = 0.087). Conclusions  Adjuvant CRT benefited a subset of patients with resected PC, particularly those with lymph node metastasis and those undergoing non-curative resection. Multivariate analysis demonstrated that patients with tumors larger than 3 cm and poor differentiation had poor prognosis.     

Internal Mammary Nodal Chain Drainage Is a Prognostic Indicator in Axillary Node-Positive Breast Cancer

Background Internal mammary (IM) nodes are a potential site of breast lymphatic drainage. We examined the relationship between lymphoscintigraphic evidence of IM drainage and survival in early-stage breast cancer patients (pts). Methods From a prospective database of 855 consecutive sentinel node mapping procedures using peritumoral radiocolloid injection from 1996–2004, we analyzed the 604 cases with stage I–III breast cancer. Overall survival and recurrence-free survival (OS, RFS) rates were compared in pts with (IM+) and without (IM-) IM drainage on lymphoscintigraphy using Kaplan-Meier plots and Cox proportional hazards models. Results: 100 of 604 pts (17%) showed IM drainage. Five-year OS and RFS were 92% vs 88% and 88% vs 85% in IM- vs IM+ pts. In the 186 pts with axillary metastases (node+), 5-year OS and RFS were 91% vs 71% and 84% vs 69% in IM- vs IM+ pts. Univariate analysis of node+ pts estimated increased mortality risk for IM+ (hazard ratio, HR 2.9, P = .04), ≥4 positive nodes (HR 3.2, P = .02), tumors that were ER-negative (HR 3.4, P = .02), or had high Ki-67 (HR 6.8, P = .01). Multivariate analysis estimated similar increased risks [≥4 nodes (HR 4.0, P = .02), IM+ (HR 3.3, P = .06), and ER negativity (HR 2.6, P = .09)]. Conclusions IM nodal drainage predicted a nearly 3-fold increased mortality risk in node+ pts. Peritumoral radiocolloid injection provides a clinically relevant assessment of IM drainage and should be prospectively tested for its value in tailoring treatment strategies for axillary node-positive pts. Presented at the 29th Annual San Antonio Breast Cancer Symposium, December 14–17, 2006.     

Sex-Based Differences in Inpatient Burn Mortality

Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences. Adult patients admitted with burn injury—including inhalation injury only—between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan–Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex. Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51). Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.     

Laparoscopic Surgery for Patients with Crohn’s Colitis: A Case-matched Study

Introduction The purpose of this study was to compare short and long-term outcomes of laparoscopic colectomy with open colectomy in patients with Crohn’s disease confined to the colon. Materials and Methods We reviewed all patients undergoing laparoscopic colectomy for Crohn’s disease at our institution between 1994 and 2005. Laparoscopic colectomies were matched to open colectomies by patient age, gender, American Society of Anesthesiologists score, type, and year of surgery. We excluded patients with concomitant small bowel disease. Results Twenty-seven laparoscopic cases were matched with 27 open cases. There were seven conversions (26%). There was no mortality. Median operative times were significantly longer after laparoscopic colectomy (240 vs 150 min, P < 0.01), and estimated blood loss was comparable (325 vs 350 ml, P = 0.4). Postoperative complications were similar. Laparoscopic colectomies had shorter median length of stay (5 vs 6 days, P = 0.07) and median time to first bowel movement (3 vs 4 days, P = 0.4). When overall length of stay included 30-day readmissions, the difference in favor of laparoscopy became statistically significant (P = 0.02). Recurrent disease requiring surgery was decreased after laparoscopy, although median follow-up was significantly shorter. Conclusion Laparoscopic colectomy is a safe and acceptable option for patients with Crohn’s colitis. Longer follow-up is needed to accurately establish recurrence rates.     

Anastomotic Leakage is Associated with Poor Long-Term Outcome in Patients After Curative Colorectal Resection for Malignancy

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24–94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02–2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23–3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07–6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome. This work was presented in the plenary session of the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Los Angeles on 22 May 2006.     

Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3828 Gastric Bypass Cases

Introduction Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome. Methods Retrospective review of 3,828 gastric bypass procedures. Results Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037). Discussion Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak. This paper was presented at The Society for Surgery of the Alimentary Tract, 47th Annual Meeting at Digestive Disease Week 2006, May 20–24, 2006, Los Angeles, California.     

Laparoscopic Versus Open Ileo-Colonic Resection in Crohn’s Disease: Short- and Long-Term Results from a Prospective Longitudinal Study

Possible relations between surgical approaches, frequency, and severity of Crohn’s disease recurrence after ileo-colonic resection is unknown. We aimed to assess perioperative outcomes and postsurgical complications of laparoscopic versus standard open surgery and to detect differences between the two groups in endoscopical recurrence and patients’ satisfaction. Twenty-eight consecutive patients undergoing elective ileo-colonic resection by either laparoscopic approach (n = 15) or conventional open surgery (n = 13) were prospectively enrolled. No mortality or major intraoperative complications were observed in both groups. Significant differences between groups were the median operating time found shorter in the open group than in the laparoscopic group (p = 0.003), the higher dosage of pain killers needed in the open group (p = 0.05), the passage of flatus and\or stool after surgery found faster in group A (p = 0.004) and the shorter recovery period in the laparoscopic group (p = 0.007). Colonoscopy was performed in 27 patients. The frequency and pattern of recurrence did not differ between the two groups (p = 0.63). Patients’ satisfaction was significantly in favor of laparoscopy. Present findings support the feasibility and advantages in the short-term of laparoscopic ileo-colonic resection in patients with Crohn’s disease. No differences were observed in terms of frequency, time of onset, and severity of recurrence in a 1-year follow-up.     

Laparoscopic vs open resection of pancreatic endocrine neoplasms: single institution’s experience over 14 years

Background Laparoscopic resection of benign pancreatic endocrine neoplasms (PENs) has become the standard of care for tumors in the pancreatic tail. Over a 14-year period, we have resected both benign and malignant tumors of the entire pancreas laparoscopically and compared our survival and complication rates with open controls. Materials and methods We collected our data retrospectively and reviewed our outcomes with an actuarial 5-year survival according to Kaplan–Meier. Patients who underwent minimally invasive techniques were compared to patients who were approached with open techniques. Results From April 1992 to September 2006, we operated on 31 patients for PENs: 13 (42%) were operated on using open techniques and 18 (58%) laparoscopically, and conversion occurred in one patient (6%). In the laparoscopic group, eight (47%) tumors were malignant compared to six (43%) in the open group. Operative times averaged 188 min for the minimally invasive approach and 305 min for the open approach (p = 0.02). Length of stay was 25 days (range 8–82) for the laparoscopic group compared to 20 days (range 6–63; p > 0.05). Overall morbidity and fistula rates ranged from 67 to 24% in the laparoscopic group to 69 to 38% in the open group (p > 0.05). There were no postoperative mortalities. The average follow-up was 63 months for the open group and 33 months for the laparoscopic group. The overall actuarial survival rates were both 90% at 5 years. Conclusions Laparoscopic resection of benign and malignant PENs has similar overall complication and 5-year survival rates as the open technique; however, the laparoscopic approach is associated with shorter operative times.     

National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn’s Disease: A Population-Based Analysis of Laparoscopic vs. Open Approaches

Purpose  The laparoscopic approach to Crohn’s disease has demonstrated benefits in several small series. We sought to examine its use and outcomes on a national level. Methods  All admissions with a diagnosis of Crohn’s disease requiring bowel resection were selected from the 2000–2004 Nationwide Inpatient Sample. Regression analyses were used to compare outcome measures and identify independent predictors of undergoing laparoscopy. Results  Of 396,911 patients admitted for Crohn’s disease, 49,609 (12%) required surgical treatment. They were predominately Caucasian (64%), female (54%), and with ileocolic disease (72%). Most had private insurance (71%) and had surgery in urban hospitals (91%). Laparoscopic resection was performed in 2,826 cases (6%) and was associated with lower complications (8% vs. 16%), shorter length of stay (6 vs. 9 days), lower charges ($27,575 vs. $38,713), and mortality (0.2% vs. 0.9%, all P < 0.01). Open surgery was used more often for fistulas (8% vs. 1%) and when ostomies were required (12% vs. 7%). Independent predictors of laparoscopic resection were age <35 [odds ratio (OR) = 2.4], female gender (OR = 1.4), admission to a teaching hospital (OR = 1.2), ileocecal location (OR = 1.5), and lower disease stage (OR = 1.1, all P < 0.05). Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative method (P > 0.05). Conclusions  A variety of patient- and system-related factors influence the utilization of laparoscopy in Crohn’s disease. Laparoscopic resection is associated with excellent short-term outcomes compared to open surgery. “The views expressed in the article (book, speech, etc.) are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the US Government.” “The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.”     

Attempted Salvage Resection for Recurrent Gastric or Gastroesophageal Cancer

The purpose of this study was to determine the outcome of surgery for patients with recurrent gastric or gastroesophageal cancer. We queried records from 7,459 patients who presented with gastric or gastroesophageal cancer to our institution from 1973 through 2005 to identify those for whom resection of recurrent disease had been attempted. We assessed the associations between various clinicopathologic factors and resectability with logistic regression analysis and between clinicopathologic factors and overall survival (OS) with the Cox proportional hazards model. Sixty patients underwent attempted resection for recurrent cancer. In 31 cases (52%), recurrent disease proved unresectable at laparotomy. Factors associated with the ability to undergo re-resection included neoadjuvant treatment prior to initial resection [odds ratio (OR) 12.2, 95% confidence interval (CI) 1.9–75.6] and having an isolated local recurrence (OR 5.1, 95% CI 1.3–20.5). Of the 29 patients who underwent re-resection, 14 required adjacent organ resection, and 6 required interposition grafting. Three- and 5-year OS rates for all 60 patients were 21% and 12%, respectively; median follow-up time was 23 months. Median OS for patients undergoing resection was 25.8 months (95% CI 17.1–49.8) versus 6.0 months (95% CI 4.0–10.5) for unresectable patients (P < 0.001). Initial tumor location at the gastroesophageal junction was associated with diminished OS [hazard ratio (HR) 2.8, 95% CI 1.2–6.5] and ability to undergo resection of recurrence was associated with improved OS (HR 0.2, 95% CI 0.1–0.6). We conclude that surgical resection of select patients with recurrent gastric or gastroesophageal cancer can result in improved OS but often requires adjacent organ resection or interposition graft placement.     

Laparoscopic Versus Open Surgery for Stage I Rectal Cancer: Long-term Oncologic Outcomes

Background

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

Methods

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

Results

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3 %; p = 1.00), morbidity (31.3 vs. 25.0 %; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0 %; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1 %; p = 0.41) or DFS (98.2 vs. 96.4 %; p = 0.30) between the open and laparoscopy groups.

Conclusions

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.     

Laparoscopic Versus Open Surgery for Rectal Cancer: A Meta-Analysis

Background Laparoscopic rectal cancer surgery aims to provide patients with curative resection while minimizing postoperative morbidity and mortality. This study used meta-analytical techniques to compare laparoscopic and open surgery as the primary treatment for patients with rectal cancer with regard to short-term and long-term outcomes. Methods A literature search was performed on all studies between 1993 and 2004 comparing laparoscopic and open surgery for rectal cancer. Subgroup analysis was performed on patients undergoing abdominoperineal excision of the rectum. The following end points were evaluated: operative outcomes, postoperative recovery, and early and late adverse events. Results Twenty studies matched the selection criteria and reported on 2071 subjects, of whom 909 (44%) underwent laparoscopic and 1162 (56%) underwent open surgery for rectal cancer. Time to stomal function (weighted mean difference [WMD], −1.52; 95% confidence interval [95% CI], −2.20, −1.01), first bowel movement (WMD, −.72; 95% CI, −1.21, −.22), feeding solids (WMD, −.92; 95% CI, −1.35, −.50), and length of hospital stay (WMD, −2.67; 95% CI, −3.81, −1.54) were all significantly reduced after laparoscopic surgery. In patients who underwent abdominoperineal excision of the rectum, wound infection (odds ratio, .15; 95% CI, .03, .73) and requirement for postoperative parenteral analgesia (WMD, −.63; 95% CI, −1.22, −.04) were also significantly reduced. There was no difference between groups in the extent of oncological clearance. Conclusions Laparoscopic rectal cancer surgery results in an earlier postoperative recovery and a resected specimen that is oncologically comparable to open surgery. Results from randomized trials reporting long-term outcomes such as cancer recurrence (local and metastatic) and 5-year survival are eagerly awaited.