Hand-Assisted Laparoscopic vs. Laparoscopic Colorectal Surgery: A Multicenter, Prospective, Randomized Trial

Purpose  This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery. Methods  Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups. Results  There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 ± 58 vs. 208 ± 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 ± 31 vs. 184 ± 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68). Conclusions  In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not available Drs. Marcello, Read, and Mutch are consultants for Applied Medical and have received honoraria and potential stock options. Drs. Milsom and Whelan have received honoraria for speaking on behalf of Applied Medical. Applied Medical provided financial support to the institutions for the project.     

Laparoscopic Total Colectomy: An Evolutionary Experience

Purpose Laparoscopic total abdominal colectomy and total proctocolectomy are technically challenging operations. Advances in minimally invasive techniques, including sleeveless hand-assist devices, may influence performance of these procedures. This study was designed to evaluate the results of laparoscopic total colectomy and to compare the hand-assisted approach with straight laparoscopy. Methods Sequential patients undergoing hand-assisted and straight laparoscopic total abdominal colectomy and total proctocolectomy from 1997 to 2004 were identified from a single institution prospective database involving four colorectal surgeons, of which three had limited laparoscopic experience. Patient characteristics, perioperative parameters, and outcomes were assessed. Results A total of 130 patients were analyzed. Sixty-nine patients underwent total abdominal colectomy (hand-assisted 17 vs. straight laparoscopic 52), and 61 underwent total proctocolectomy (hand-assisted 28 vs. straight laparoscopic 33). For both total abdominal colectomy and total proctocolectomy, the hand-assisted and straight laparoscopic groups were well matched. Although no differences were observed in operative blood loss and intraoperative complications, hand assistance resulted in fewer overall conversions to open (1/45 (2.2 percent) vs. 6/85 (7.1 percent); P < 0.01), with no conversions in the total abdominal colectomy group (0 vs. 9.6 percent; P = 0.05). There was a trend toward reduced operative time with hand assistance, and nonlaparoscopic staff surgeons performed a greater proportion of the hand-assisted cases (22.2 vs. 10.6 percent; P < 0.05). Conclusions Laparoscopic total colectomy is technically feasible and safe. With a significant reduction in conversions and a greater proportion of cases performed by nonlaparoscopic surgeons, there was an evolutionary shift to a hand-assisted technique. A hand-assisted approach may be a useful alternative to a straight laparoscopic approach for this technically challenging operation. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Dr. Marcello is a consultant for Applied Medical, Ethicon Endo-Surgery, Olympus, and Valleylab. He has received honoraria from each company.     

Laparoscopic- <Emphasis Type="Italic">vs.</Emphasis> Hand-Assisted Ultralow Anterior Resection: A Prospective Study

Purpose A standard laparoscopic-assisted operation can be conducted with colorectal anastomosis performed after extraction of specimen and insertion of a pursestring via a small left iliac fossa or suprapubic incision, or completed via hand-assisted laparoscopic technique with a 7-cm to 8-cm suprapubic incision. This study compares the short-term outcomes of either technique. Methods Sixty-three consecutive patients undergoing laparoscopic-assisted ultralow anterior resection or total mesorectal excision for rectal cancer were examined. The laparoscopic-assisted group (n = 31) had standard laparoscopic-assisted resection, whereas the hand-assisted laparoscopic group (n = 32) had a 7-cm to 8-cm suprapubic incision to allow an open colorectal anastomosis. In patients who were obese or have had multiple abdominal surgeries, the hand-assisted approach was generally favored. All patients had a diverting ileostomy. Results There was no conversion in either group. Mean operating time was significantly longer in the laparoscopic-assisted group (188.2 vs. 169.8 minutes; P < 0.0001). Mean duration for narcotic analgesia (1.65 vs. 3.38 days, P < 0.0001), mean time to flatus (1.97 vs. 3.19 days, P < 0.0001), and mean duration of intravenous hydration (2.45 vs. 3.88 days, P < 0.0001) were longer in the hand-assisted laparoscopic group. However, the mean length of hospital stay (5.8 vs. 5.9 days, P = 0.379) was similar. There was no major surgical complication in either group; chest infection, wound infection, and thrombophlebitis were similar between the laparoscopic-assisted group and the hand-assisted laparoscopic group. Adequacy of specimen harvest (distal tumor margins, P = 0.995; circumferential resection margin, P = 0.946; number of lymph nodes, P = 0.845) was similar. Conclusions Although both laparoscopic-assisted and hand-assisted laparoscopic surgeries are safe and feasible for ultralow anterior resection, the hand-assisted technique significantly shortens operating time. †Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Subtotal colectomy with antiperistaltic cecoproctostomy for selected patients with slow transit constipation—from Chinese report

Background and aims  Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) is recommended widely for the patients with severe, refractory slow transit constipation (STC). Subtotal colectomy with end-to-end antiperistaltic cecorectal anastomosis (Sarli procedure), an alternative for STC, has been paid particular attention. The purpose of this study was to retrospectively compare alterations of clinical functions and qualities of life between TAC-IRA and Sarli procedure. Methods  Seventeen patients with STC who underwent Sarli procedure and 20 patients with STC who underwent TAC-IRA were chosen for this study. Patient characteristics, operative data, postoperative data, alterations of clinical function, and quality of life were compared. The gastrointestinal quality of life index (GIQLI) survey was used to evaluate postoperative qualities of life. Results  At the mean 4-year follow-up (range 2–6 years), the frequency of daily bowel movement in the Sarli group was significantly less than that in the TAC-IRA group (2.4 ± 0.9 vs. 3.4 ± 0.8; P = 0.0014), and the Wexner continence scores were significantly lower in the Sarli group compared to the TAC-IRA group (4.3 ± 1.8 vs. 5.8 ± 1.9; P = 0.0223). However, the GIQLI score in Sarli group was higher than the TAC-IRA group (119.8 ± 7.5 vs. 111.1 ± 12.0, P = 0.0455). Post subtotal colectomy barium enema showed a sign of “reservoir” at the residual ascending colon and cecum. Conclusions  Compared to the TAC-IRA, subtotal colectomy with end-to-end antiperistaltic cecoproctostomy for appropriately selected patients with STC resulted in relief of constipation, satisfactory functional outcome, and improved qualities of life.     

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial

Background  Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections. Materials and methods  Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea. Results  One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups. Conclusion  Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.     

Visceral Obesity Predicts Surgical Outcomes after Laparoscopic Colectomy for Sigmoid Colon Cancer

Purpose  This study was designed to assess whether visceral obesity is a more useful predictor of surgical outcomes compared with body mass index after laparoscopic colectomy. Methods  A total of 133 consecutive patients who underwent elective laparoscopic colectomy for sigmoid colon cancer between April 2001 and April 2007 were included. Obesity was defined by visceral fat area ≥130 cm² or body mass index ≥25 kg/m², and the variables were compared for obese and nonobese patients. Results  There were 68 (51.1 percent) obese patients according to visceral fat area and 27 (20.3 percent) according to body mass index. Using either definition, obese patients had a significantly longer operative time compared with nonobese patients. Patients classified as obese by visceral fat area had a significantly higher incidence of wound infection (20.6 vs. 4.6 percent; P = 0.006) and overall complication rates (32.4 vs. 12.3 percent, P = 0.006) compared with nonobese patients, whereas there was no significant difference when classified by body mass index. Postoperative hospital stay was significantly longer in obese patients compared with nonobese patients classified by visceral fat area (median 10.5 vs. 9 days; P = 0.007), whereas it was not statistically different when classified by body mass index. Conclusion  Visceral fat area is a more useful parameter than body mass index in predicting surgical outcomes after laparoscopic colectomy for sigmoid colon cancer. Presented at the Biennial Congress of International Society of University Colon and Rectal Surgeons, Istanbul, Turkey, June 25 to 28, 2006.     

Measuring gastric emptying of semisolids in children using the C-acetate breath test: a validation study

Background and aim. Radioscintigraphy is the gold standard for evaluation of gastric emptying in children, but requires exposure to ionising radiation. Therefore, the aim of the study was to validate the non-radioactive ¹³C-acetate breath test in children in comparison to radioscintigraphy as reference method.Patients. Twenty-nine children with dyspeptic or respiratory symptoms were tested for gastric emptying disorders simultaneously performing the ¹³C-acetate breath test and radioscintigraphy.Methods. A semisolid oatmeal was doubly labelled with 150 mg ¹³C-acetate and 50 MBq ^99mTechnetium. Breath samples were collected every 5–10 min for 4 h. After mass spectrometrical ¹³C-analysis, curve fitting of the ¹³C-cumulative recovery to the modified power exponential function Y=m(1−e^−kt)^β calculated the half emptying times of the breath test (t_1/2^breath). Scintigraphic image acquisition began immediately after the ingestion of the ^99mTechnetium-labelled testmeal at a rate of one frame every 60 s for 1 h.Results. Six children showed delayed gastric emptying in scintigraphy (t_1/2^scinti>60 min). All these children had prolonged half emptying times t_1/2^breath in the ¹³C-acetate breath test. Using a cut-off t_1/2^breath>90 min, the ¹³C-acetate breath test had a sensitivity of 100% and a specificity of 85%. Scintigraphic and breath test half emptying times were linearly correlated (Y=0.80x+47.68, r=0.76, P<0.00001).Conclusions. The ¹³C-acetate breath test proves to be a reliable, non-radioactive alternative for measuring gastric emptying in children.     

Fast-Track Surgery May Reduce Complications Following Major Colonic Surgery

Purpose  Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular; however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. Methods  From December 2005 to March 2007, consecutive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program. Results  Fifty patients were included in each group. Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P < 0.001). The numbers of patients with urinary infections (2 vs. 12, P = 0.008), ileus (5 vs. 18, P = 0.005), and cardiopulmonary complications (11 vs. 21, P = 0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. Conclusion  Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery. Presented at the Annual Scientific Congress of the Royal Australasian College of Surgeons, May 6 to 11, 2007, Christchurch, New Zealand This research was conducted during tenure of a Clinical Research Training Fellowship from Health Research Council of New Zealand.     

Use of Chewing Gum in Reducing Postoperative Ileus After Elective Colorectal Resection: A Systematic Review

Purpose Published studies comparing the addition of chewing gum to standardized postoperative care to shorten postoperative ileus showed controversial results. This study was designed to conduct a systematic review of all relevant trials on chewing gum to reduce postoperative ileus after colorectal resection. Methods All published trials that compared the additional use of gum chewing with standard postoperative management were identified from Ovid MEDLINE, EMBASE, CINAHL, and All Evidence-Based Medicine Reviews between January 1991 and January 2007. The clinical outcomes were extracted and meta-analysis was performed by Forest plot review. Results Five randomized, controlled trials with 158 (94 males) patients with mean age of 61.9 years were included. Seventy-eight patients received an addition of gum chewing and 80 had standard postoperative care for colorectal resection. Operating time (P = 0.78) and blood loss (P = 0.48) were similar. All patients tolerated the gum without any side-effects. With combined standard postoperative care and gum chewing, the patients passed flatus 24.3 percent earlier (weighted mean difference, −20.8 hours; P = 0.0006) and had bowel movement 32.7 percent earlier (weighted mean difference, −33.3 hours; P = 0.0002). They were discharged 17.6 percent earlier than those having ordinary postoperative treatment (weighted mean difference, −2.4 days; P < 0.00001). The gum-chewing group was associated with similar overall postoperative complication rate (odds ratio, 0.45; P = 0.05) with individual complication showing a trend favoring gum chewing, although they were not of statistical significance. Readmission (odds ratio, 0.36; P = 0.24) and reoperation rates (odds ratio, 1.36; P = 0.83) of the two groups were similar. Conclusions The use of gum chewing in the postoperative period is a safe method to stimulate bowel motility and reduce ileus after colorectal surgery. Presented at the 20th World Congress of International Society for Digestive Surgery, Rome, Italy, November 29 to December 2, 2006.     

Gastric emptying of liquid and solid meals at various temperatures Effect of meal temperature for gastric emptying

Background  Patients with functional dyspepsia frequently show delayed gastric emptying, and dietary advice is frequently given for its improvement. If meal temperature influences gastric emptying, advice regarding the meal temperature may become a possible component of dietary therapy. However, little information exists concerning the thermal effect of meals on gastric emptying. The aim of this study was to determine the thermal effect of liquid and solid meals on gastric emptying. Methods  The gastric emptying of liquid and solid test meals was examined in healthy volunteers (liquid, n = 25, mean age = 35.7 ± 9.6 years, male-to-female ratio = 22:3; solid, n = 25, mean age = 35.2 ± 8.8 years, male-to-female ratio = 20:5). Gastric emptying after the ingestion of liquid or solid meals at three different temperatures (4, 37, and 60°C) was investigated with the [¹³C]-labeled acetate breath test. The lag phase time (T _max-calc) and the half-emptying time (T _1/2) were calculated from the ¹³CO₂ breath excretion curve as indices of gastric emptying. Results  The values of T _max-calc at 60°C with both the liquid and solid meals were significantly smaller than those at 37°C (P < 0.05). However, there was no difference in the T _1/2 values. In the analysis of the percent excretion of ¹³CO₂ in 1 h (% dose/h) data with the liquid meal test in the earlier phase within 30 min, significantly larger values were found at 60°C than at the other temperatures. These findings suggest that a hot meal significantly accelerates gastric emptying. Conclusions  Meal temperature may be considered as a component of dietary therapy for patients with functional dyspepsia.     

A Sprayable Hydrogel Adhesion Barrier Facilitates Closure of Defunctioning Loop Ileostomy: A Randomized Trial

Purpose  Closure of defunctioning loop ileostomy often is associated with division of complex peristomal adhesions through a parastomal incision with limited exposure. The goal was to determine whether sprayable hydrogel adhesion barrier (SprayGel™) will reduce peristomal adhesions and facilitate closure of ileostomy. Methods  Patients undergoing closure of loop ileostomy were randomized to have hydrogel adhesion barrier sprayed around both limbs of ileostomy for 20 cm (SprayGel™ group, n = 19), or to control without adhesion barrier (control group, n = 21). Ileostomy was reversed at ten weeks after construction. Extent of peristomal adhesions was scored in blinded manner (each quadrant, range, 1–3: 3 = most severe; total, range, 4–12: 12 = most severe). Results  Use of adhesion barrier was associated with significant reduction in overall adhesion scores (mean, 6.11 vs. 9.67; P < 0.0005), four-quadrant adhesion scores (Quadrant A: 1.68 vs. 2.52, P = 0.002; Quadrant B: 1.42 vs. 2.33, P < 0.0005; Quadrant C: 1.42 vs. 2.24, P < 0.0005; Quadrant D: 1.58 vs. 2.48, P = 0.002), and proportion of patients with dense (scores ≥ 8) adhesions (0.11 vs. 0.71; P < 0.0005). Time taken to mobilize (16.53 vs. 21.67 minutes; P = 0.008) and close ileostomy (35.37 vs. 41.90 minutes; P = 0.008) was significantly reduced. Postoperative complications were comparable. Conclusions  A sprayable hydrogel adhesion barrier placed around the limbs of a defunctioning loop ileostomy reduced peristomal adhesions and might facilitate closure of ileostomy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. †Deceased. Supported by the Confluent Surgical Inc., the manufacturer of SprayGel™.     

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

Purpose  The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. Methods  From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Results  Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04). Conclusions  Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.     

Desirable pharmacokinetic properties of 13C-uracil as a breath test probe of gastric emptying in comparison with 13C-acetate and 13C-octanoate in rats

Objective. To investigate the possible use of a ¹³C-uracil breath test for gastric emptying by evaluating the pharmacokinetic properties of ¹³C-uracil in a breath test in rats, in comparison with ¹³C-acetate and ¹³C-octanoate, traditional ¹³C-probes for gastric emptying. Material and methods. Absorption of the ¹³C-probes from different parts of the gastrointestinal tract was evaluated in fasted rats. ¹³C-Uracil breath tests for gastric emptying were carried out in conditions where delayed gastric emptying was induced by clonidine, quinpirole, and propantheline, and in a postoperative ileus model. Following oral administration, we measured residual ¹³C-uracil in the stomach and correlated the amount with the breath response. Results. All the ¹³C-probes employed were well absorbed from the intestine after intraduodenal administration. After intragastric administration, ¹³C-uracil was not absorbed from the stomach, but ¹³C-acetate and ¹³C-octanoate were partly absorbed from the stomach. The cumulative ¹⁴C-uracil recovery (%) at 168 h was 92.3, 6.3, or 0.5%, from expired gases, urine, and feces, respectively. Δ¹³C values in ¹³C-uracil breath tests were decreased in conditions characterized by delayed gastric emptying. A highly negative correlation was observed between the breath response and the residual ratio of ¹³C-uracil in the stomach after oral administration of ¹³C-uracil, indicating that ¹³C-uracil can be used as an in vivo probe for evaluating gastric emptying in a quantitative manner. Conclusions. This study showed that ¹³C-uracil has desirable pharmacokinetic properties as an in vivo probe of gastric emptying. It is thus suggested that the ¹³C-uracil breath test may be useful for the measurement of gastric emptying in humans.     

Aperitif Effects on Gastric Emptying: A Crossover Study Using Continuous Real-Time 13C Breath Test (BreathID System)

The aim of this study was to determine whether there is a correlation between aperitif and gastric emptying. Ten healthy male volunteers participated in this randomized, two-way crossover study. Under two conditions (after drinking an aperitif versus not), the ¹³C breath test was performed for 4 h with a liquid meal (200 kcal/200 ml) containing 100 mg ¹³C acetate. We used 50 ml of umeshu as the aperitif. This is a traditional Japanese plum liqueur, and contains 7 ml alcohol (14%). In the aperitif group, T _1/2, T _lag, and T _peak were significantly delayed [T _1/2 (132: 113–174) versus (112: 92–134) (P = 0.0069); T _lag (80: 63–94) versus (55: 47–85) (P = 0.0069); and T _peak (81: 62–96) versus (54: 34–84) (P = 0.0069), (median: range, aperitif versus control, min)]. Gastric emptying was significantly delayed in the aperitif group as compared with the control group. This study revealed that even a small amount of alcohol such as an aperitif may contribute to delayed gastric emptying.     

Total Laparoscopic Restorative Proctocolectomy: Are There Advantages Compared with the Open and Hand-Assisted Approaches?

Purpose A randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy with open surgery did not show an advantage for the laparoscopic approach. The trial was criticized because hand-assisted laparoscopic restorative proctocolectomy was not considered a true laparoscopic proctocolectomy. The objective of the present study was to assess whether total laparoscopic restorative proctocolectomy has advantages over hand-assisted laparoscopic restorative proctocolectomy with respect to early recovery. Methods Thirty-five patients underwent total laparoscopic restorative proctocolectomy and were compared to 60 patients from a previously conducted randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy and open restorative proctocolectomy. End points included operating time, conversion rate, reoperation rate, hospital stay, morbidity, quality of life, and costs. The Medical Outcomes Study Short Form 36 and the Gastrointestinal Quality of Life Index were used to evaluate general and bowel-related quality of life. Results Groups were comparable for patient characteristics, such as sex, body mass index, preoperative disease duration, and age. There were neither conversions nor intraoperative complications. Median operating time was longer in the total laparoscopic compared with the hand-assisted laparoscopic group (298 vs. 214 minutes; P < 0.001). Morbidity and reoperation rates in the total laparoscopic, hand-assisted laparoscopic, and open groups were comparable (29 vs. 20 vs. 23 percent and 17 vs.10 vs. 13 percent, respectively). Median hospital-stay was 9 days in the total laparoscopic group compared with 10 days in the hand-assisted laparoscopic group and 11 days in the open group (P = not significant). There were no differences in quality of life and total costs. Conclusions There were no significant short-term benefits for total laparoscopic compared with hand-assisted laparoscopic restorative proctocolectomy with respect to early morbidity, operating time, quality of life, costs, and hospital stay.     

Laparoscopic Resection in Rectal Cancer Patients: Outcome and Cost-Benefit Analysis

Purpose This study was designed to evaluate the impact of laparoscopic rectal resection on short-term postoperative morbidity and costs. Methods A total of 168 patients with rectal cancer were randomly assigned to laparoscopic (n = 83) or open (n = 85) resection. Outcome parameters were: postoperative morbidity, length of hospital stay, quality of life, long-term survival, and local recurrences. The mean follow-up period was 53.6 months. Cost-benefit analysis was based on hospital costs. Results Operative time was 53 minutes longer in the laparoscopic group (P < 0.0001). Postoperative morbidity rate was 28.9 percent in the laparoscopic vs. 40 percent in the open group (P = 0.18). The mean length of hospital stay was 10 (4.9) days in the laparoscopic group and 13.6 (10) days in the open group (P = 0.004). Local recurrence rate and five-year survival were similar in both groups; however, the limited number of patients does not allow firm conclusions. Quality of life was better in the laparoscopic group only in the first year after surgery (P < 0.0001). The additional charge in the laparoscopic group was $1,748 per patient randomized ($1,194 the result of surgical instruments and $554 the result of longer operative time). The saving in the laparoscopic group was $1,396 per patient randomized ($647 the result of shorter length of hospital stay and $749 the result of the lower cost of postoperative complications). The net balance resulted in $351 extra cost per patient randomly allocated to the laparoscopic group. Conclusions Short-term postoperative morbidity was similar in the two groups. Laparoscopic resection reduced length of hospital stay, improved first-year quality of life, and slightly increased hospital costs. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Predicting factors of postoperative relapse in T2-4N0M0 colorectal cancer patients via harvesting a minimum of 12 lymph nodes

Background and aim  The aim of this retrospective study was to determine which clinicopathological factors influenced the incidence of postoperative relapse and overall survival rates after radical resection of T_2-4N₀M₀ colorectal cancer (CRC) patients via harvesting a minimum of 12 lymph nodes. Materials and methods  Between January 2001 and June 2006, a total of 342 T_2-4N₀M₀ CRC patients who underwent radical resection were retrospectively analyzed in Kaohsiung Medical University Hospital. Of these 342 patients, 155 were observed by harvesting a minimum of 12 lymph nodes. These 155 patients were followed up intensively, and their outcomes were investigated retrospectively. Results  Of 155 patients, 83 were men (53.5%) and 72 (46.5%) were women. The mean age was 65.5 ± 11.1 years (range, 24–89 years). The median follow-up period was 49 months (range, 19–80 months). The present data showed invasive depth (P = 0.012), vascular invasion (P < 0.001), and perineural invasion (P = 0.009) as significantly prognostic factors for postoperative 5-year relapse rate by Kaplan–Meier analysis. Likewise, invasive depth (P = 0.013), vascular invasion (P < 0.001), and perineural invasion (P = 0.008) were significant factors for postoperative 5-year survival rate. Meanwhile, using a Cox proportional hazards analysis, depth of tumor invasion (P = 0.026) and vascular invasion (P = 0.001) were the independent predictors for postoperative relapse. Furthermore, the presence of vascular invasion was considerably correlated to the higher postoperative relapse rate and the poorer overall survival rates by survival analyses (P < 0.0001). Conclusions  Besides the conventional depth of tumor invasion, this study highlights the potential for using vascular invasion as a means of identifying a subgroup of T_2-4N₀M₀ CRC patients with adequate lymph node harvest at higher risk who would potential benefit from adjuvant therapy after surgery.     

Influence of cisapride on gastric emptying of solids and liquids monitored by13C breath tests

[¹³C]Acetate and [¹³C]octanoate breath tests were used to analyze the gastric emptying of liquids and solids in healthy controls and patients with functional dyspepsia both with and without cisapride. A standard test meal was labeled with either 150 mg [¹³C]acetate (liquid phase labeled in the water) or with 100 mg [¹³C]octanoate (solid phase labeled in the egg yolk). Six patients with dyspepsia and six healthy controls underwent a 4-hr breath test four times, ie, both the [¹³C]acetate and [¹³C]octanoate test with and without cisapride. Duplicate [¹³C]acetate or [¹³C]octanoate breath tests were performed in another 12 healthy controls in order to assess day-to-day variability of gastric emptying for liquids and solids. The mass spectrometric data were fitted to a power exponential function allowing mathematical analysis of half-emptying times and lag times. In patients with dyspepsia, gastric half emptying times of solids were significantly delayed as compared to the emptying of solids in the controls (203±41 vs 148±35 min;P<0.05). With cisapride, gastric emptying of solids was significantly accelerated (P<0.05) both in the patients (166±58 min) and in the controls (117±27 min). The gastric emptying of liquids did not differ in patients and controls, and cisapride had no effect on the emptying of liquids within the normal range. In the healthy controls, half emptying times both for liquids and solids were reproducible on the two different days (CV_intra: 5.58% for liquis, 20.01% for solids). We conclude that as an entirely noninvasive and nonradioactive tool¹³C-labeled breath tests are well reproducible and allow assessment of the effect of cisapride on the characteristics of gastric emptying.     

Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> 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. Presented in part at the EAES (Europian Society of Endoscopic Surgeons) Congress, June 1 to 4, 2005, Venice, Italy     

Omentoplasty in rectal cancer surgery prolongs post-operative ileus

Backgrounds and aim Omentoplasty is frequently used as a safeguard in rectal cancer surgery for wrapping the anastomosis or filling up the pelvic cavity. The omentum is known for its infection defence and haemostatic and angiogenic properties. A disadvantage was hypothesized to be prolonged post-operative ileus, as omentoplasty interrupts the blood flow from an epiploic artery to the stomach. Materials and methods Patients who had had an uncomplicated surgical treatment for primary rectal cancer between January 2006 and March 2007 were included. Clinical parameters of post-operative ileus were collected and compared between procedures with a concomitant omentoplasty (n = 31) and without (n = 20). Results Patients needed their gastric tube significantly longer after omentoplasty than those without (3.9 vs 1.6 days, p < 0.001). Similar significant results were found for time to normal diet (p = 0.004), time to first discharge of faeces (p = 0.007), need for parenteral feeding (p = 0.036) and length of hospital stay (p = 0.008). Furthermore, there was a non-significant trend for more days to first discharge of air (3.4 vs 2.4 days, p = 0.165). There were no significant differences in patients’ and procedure characteristics, except for more low anterior resections in the group without an omentoplasty (p < 0.001). None of these characteristics had any clinically relevant interference with the parameters of post-operative ileus. Conclusion A trend for prolonged post-operative ileus was found in patients who underwent an omentoplasty concomitant with their treatment for primary rectal cancer. When assessing the importance of omentoplasty in the future, post-operative ileus should be taken into account.