Does laparoscopic abdominoperineal resection of the rectum compromise long-term survival?

PURPOSE: Laparoscopic techniques for bowel resection have not enjoyed widespread popularity. Of concern is that long-term follow-up data of cancer specific outcomes is not yet available. The aim of our study was to examine the long-term outcome of abdominoperineal resection for cancer done laparoscopically compared with a similar cohort who underwent open surgery. METHODS: A retrospective review was performed of all abdominoperineal resections done in our center between 1992 and 2000, comparing the cancer-specific outcomes of the laparoscopic cohort with the open cohort. The analysis was performed on an intention-to-treat basis and survival analysis was calculated by the techniques of Kaplan-Meier. RESULTS: Eighty-nine patients were reviewed. Twenty-eight operations were done laparoscopically, and 61 were open. The two groups were matched for age and stage of disease. There was no difference in mean length of overall survival (open = 30.3 months; laparoscopic = 40.8 months; P = 0.355 log rank). No difference in overall recurrence rate, isolated recurrence rate, or distant recurrence rates was seen nor was there any difference in the disease-free period. There was no difference in the number of lymph nodes harvested from the resected specimens, and the distance to the lateral margins or involvement of tumor in the lateral margins between the two groups was the same. The laparoscopic cohort did have a significantly shorter length of stay (mean, 13 days) compared with the open cohort (mean, 18 days), P = 0.008 Mann-Whitney U test. CONCLUSIONS: Laparoscopic abdominoperineal resection of the rectum for cancer does not compromise cancer-specific survival outcomes. The patients avoid a large abdominal wound, which improves cosmesis and presumably is responsible for the significantly shorter length of stay.     

Successful application of laparoscopic surgery to the treatment of Crohn's disease with fistulas

PURPOSE: The role of laparoscopic surgery in patients with Crohn's disease remains to be defined, although increasingly difficult cases are being treated using minimally invasive techniques. We examined technical feasibility in 20 patients with Crohn's disease associated with fistulas. METHODS: Laparoscopic surgery was attempted in 37 patients with stricturing ileal disease or ileocolonic Crohn's disease from 1994 to 2000 after failure of strict nutritional therapy. Twenty of these patients with a total of 31 intestinal fistulas (14 ileoileal, 6 ileocolonic, 5 ileorectal, 2 ileovesical, 2 ileocutaneous, 1 gastrocolic, and 1 ileoduodenal) underwent 25 operations. Fistulas were divided intracorporeally, except for ileoileal fistulas. Fifteen patients underwent ileocecal resection; six underwent strictureplasty; six underwent partial resection of the small intestine; three underwent segmental colonic resection; and one underwent resection of anastomotic recurrence. Median follow-up was 48 (range, 5-77) months. RESULTS: Oral intake was started a median of 1 (range, 1-9) day after operation, and patients were discharged a median of 8 (range, 6-21) days after surgery. Four complications were observed in 25 operations (16 percent), including 1 intestinal obstruction/ileus, 2 wound infections, and 1 intra-abdominal abscess. There were no intraoperative or postoperative deaths. Four of the 5 operations were converted to open surgery (16 percent). Three of the 5 patients (60 percent) who required reoperation for anastomotic recurrence underwent repeated laparoscopic surgery using the same small incision. CONCLUSION: Laparoscopic treatment for Crohn's disease complicated by fistulas is feasible without high complication or conversion rates. Recurrent disease requiring reoperation can also be successfully treated using laparoscopic methods.     

Laparoscopic surgery in the management of Crohn's disease

Crohn's disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990's, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn's disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn's disease.     

Is There Any Difference in Recurrence Rates in Laparoscopic Ileocolic Resection for Crohn's Disease Compared With Conventional Surgery? A Long-Term, Follow-Up Study

Purpose The long-term outcome of laparoscopic ileocolic resection in patients with Crohn's disease is not well defined. This study was designed to define the surgical recurrence rate after laparoscopic ileocolic resection for Crohn's disease and to compare it with that seen after open ileocolic resection. Methods A retrospective review of 113 records of patients who underwent index ileocolic resection for terminal ileal Crohn's disease was performed (1987–2003). Recurrence was defined as development of new preanastomotic Crohn's disease requiring surgical intervention. Details of recurrence and use of chemoprophylaxis was determined by phone interview andchart review. Results Sixty-three patients (26 males; mean age, 35.2 years) underwent laparoscopic ileocolic resection and 50 had open ileocolic resection (17 males; mean age, 37.1 years). Surgical recurrence developed in 6of 63 patients (9.5 percent) in the laparoscopic ileocolic resection group (mean follow-up, 62.9 months) and in 12of 50 patients (24 percent) in the open ileocolic resection group (mean follow-up, 81.8 months). Rates of chemoprophylaxis were similar between groups (laparoscopic ileocolic resection, 39 percent; open ileocolic resection, 54 percent; P = not significant). Median times to recurrence after laparoscopic ileocolic resection and open ileocolic resection were 60 (range, 36–72) months and 62 (range, 12–180) months, respectively. Fifty percent of the recurrences in the laparoscopic ileocolic resection group and 4 of 12 in the open ileocolic resection group were able to be retreated laparoscopically. Re-recurrence occurred in 4 of 12 open ileocolic resection patients (33 percent) at a mean of 63.6 months, and one patient had a third recurrence at 28 months. Conclusions In this study, the long-term outcome after laparoscopic ileocolic resection was not shown to be statistically different from that of open ileocolic resection. The relatively low recurrence rates in both groups may be explained by our aggressive use of chemoprophylaxis. Poster presentation at the meeting of The American Society for Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004. Reprints are not available.     

Oncologic outcome of laparoscopic versus open surgery for advanced colorectal cancer.

BACKGROUND/AIMS: Laparoscopic colorectal surgery for advanced colorectal carcinoma still remains controversial because of the technical difficulties in lymph node dissection, which is a routine procedure for advanced colorectal carcinoma, and uncertainty regarding the oncologic outcome after laparoscopic colectomy. This study reviewed the results of laparoscopic colectomy with lymph node dissection in patients with advanced colorectal carcinoma performed at our hospital. METHODOLOGY: The oncologic outcomes of 48 patients with advanced colorectal carcinoma who underwent laparoscopic colectomy between 1993 and 1998 were compared with those of 48 matched patients who underwent conventional open surgery during the same period or immediately before the introduction of laparoscopic surgery. RESULTS: The median follow-up for the laparoscopic group and the open colectomy group was 41 and 68 months, respectively. No port site recurrence occurred in the laparoscopic group, and the medium-term disease-free rate, overall survival rate, as well as the patterns of recurrence were comparable in the two groups. CONCLUSIONS: Oncologic outcome of laparoscopic colectomy at a minimum of two years was not compromised compared with conventional open surgery even in advanced carcinoma. However, information regarding true oncologic outcome will require careful long-term follow-up.     

A case-control-study comparing laparoscopic versusopen surgery for rectosigmoidal and rectal cancer

This study compared laparoscopic with open surgery for the cure of cancer of the rectosigmoid and rectum. Results of surgery, postoperative recovery, and oncological follow-up were compared between 32 laparoscopic curative procedures (19 laparoscopic-assisted anterior resections for cancer of the rectosigmoid or upper rectum and 13 laparoscopic abdominoperineal resections for low rectal cancer) and 32 controls matched for age, UICC stage, tumor site, and type of resection who underwent open surgery during the same observation period. Morbidity was identical after laparoscopic and open resection (31.3%). Surgery was equally radical in the two groups regarding yield of lymph nodes and lateral and distal margins. Survival, recurrence, and cancer-related mortality showed no statistical differences. There was no port-site recurrence. The benefits of laparoscopic surgery were shown with a reduction in perioperative blood transfusion and earlier return of bowel function. However, the operative time was significantly increased in the laparoscopic group. This study shows that laparoscopic surgery for the cure of colorectal cancer is technically feasible, and that oncological short-term outcome does not differ from the results achieved by open techniques. However, prospective randomized trials are mandatory to evaluate the definite role of laparoscopic surgery for malignancy. Accepted: 26 April 1999     

Comparison of long-term outcome of laparoscopic and conventional surgery for advanced colon and rectosigmoid cancer

BACKGROUND/AIMS: Although after laparoscopic surgery for colorectal cancer postoperative recovery is better than after open surgery, oncologic outcome after this minimally invasive technique remains unclear. In this study we tested the null hypothesis that there is no difference in the outcome of advanced colorectal cancer according to whether it is treated by laparoscopic or conventional open resection. METHODOLOGY: The long-term outcome of 79 patients with advanced colorectal cancer who underwent laparoscopic surgery between 1996 and 2002 was compared with that of 79 who underwent open surgery during the same period, being well-matched patients for age, gender, tumor site, and pathological TNM stage (II or III). Adjuvant therapy and postoperative follow-up were the same in both groups. RESULTS: The median follow-up time after laparoscopic and open surgery was 36 months and 47 months, respectively (p = 0.0756). No significant difference was found between the groups in overall or disease-free survival rates (96% versus 88%, p = 0.12; 96% versus 86%, p = 0.09, respectively). The recurrence rate was 23% in both groups, and liver metastasis was the most frequent form of recurrence. No port site recurrence was observed in the laparoscopic surgery group. CONCLUSIONS: The laparoscopic approach is an acceptable alternative to open surgery for advanced colorectal cancer because of the comparable medium-term outcome. Longer follow-up and large scale RCT is needed to fully assess the oncologic outcome.     

Long-term results of strictureplasty without synchronous resection for jejunoileal Crohn's disease

BACKGROUND: There have been several reports on strictureplasty for Crohn's disease. However, in most of them the majority of the patients underwent synchronous bowel resections. The efficacy of strictureplasty has been often attributed to the synchronous bowel resection. This study was undertaken to assess the long-term results of strictureplasty alone for jejunoileal Crohn's disease. METHODS: Forty-three patients who underwent 135 primary strictureplasties without synchronous resection for jejunoileal Crohn's disease between 1980 and 1997 were reviewed. Factors affecting reoperation rates were examined by using a multivariate analysis. RESULTS: There were no operative deaths. Intra-abdominal septic complications (abscess/fistula) developed in 4 patients (9%). Abdominal symptoms were relieved in all but two patients, who required further surgery within 6 months after operation. After a median follow-up of 9 years 21 patients (49%) required reoperation for small-bowel recurrence. A multivariate analysis using Cox's proportional hazard model showed that only age at operation (<35 years, hazard ratio 11.1 versus >35 years, P = 0.002) was an independent significant factor affecting the reoperation rate. Sex, duration of symptoms, smoking, previous small-bowel resection, steroids use, preoperative nutritional status, and site, number, or length of strictureplasties did not affect the reoperation rates. At present all the patients are asymptomatic and receiving neither medical treatment nor nutritional support. CONCLUSIONS: Strictureplasty is a safe and efficacious procedure for jejunoileal Crohn's disease in the long term. Only youth was an independent significant risk factor for recurrence requiring surgery.     

Laparoscopic hepatic lobectomy for symptomatic polycystic liver disease

BackgroundLaparoscopic fenestration has largely replaced open fenestration of liver cysts. However, most hepatectomies for polycystic liver disease (PCLD) are performed open. Outcomes data on laparoscopic hepatectomy for PCLD are lacking.MethodsPatients who underwent surgery for PCLD at a single institution between 2010 and 2019 were reviewed and grouped by operative approach. Pre- and post-operative volumes were calculated for patients who underwent resection. Primary outcomes were: volume reduction, re-admission and postoperative complications.ResultsTwenty-six patients were treated for PCLD: 13 laparoscopic fenestration, nine laparoscopic hepatectomy, three open hepatectomy and one liver transplantation. Median length of stay for patients after laparoscopic resection was 3 days (IQR 2–3). The only complication was post-operative atrial fibrillation in one patient. There were no readmissions. Overall volume reduction was 51% (range 22–69) for all resections, 32% (range 22–46) after open resection and 56% (range 39–69) after laparoscopic resection.ConclusionVolume reduction achieved through laparoscopic approach exceeded open volume reduction at this institution and is comparable to volume reduction in previously published open resection series. Adequate volume reduction can be accomplished by laparoscopic means with acceptable postoperative morbidity.     

Surgery for luminal Crohn’s disease

Many patients with Crohn’s disease(CD)require surgery.Indications for surgery include failure of medical treatment,bowel obstruction,fistula or abscess formation.The most common surgical procedure is resection.In jejunoileal CD,strictureplasty is an accepted surgical technique that relieves the obstructive symptoms,while preserving intestinal length and avoiding the development of short bowel syndrome.However,the role of strictureplasty in duodenal and colonic diseases remains controversial.In extensive colitis,after total colectomy with ileorectal anastomosis(IRA),the recurrence rates and functional outcomes are reasonable.For patients with extensive colitis and rectal involvement,total colectomy and end-ileostomy is safe and effective;however,a few patients can have subsequent IRA,and half of the patients will require proctectomy later.Proctocolectomy is associated with a high incidence of delayed perineal wound healing,but it carries a low recurrence rate.Patients undergoing proctocolectomy with ileal pouch-anal anastomosis had poor functional outcomes and high failure rates.Laparoscopic surgery has been introduced as a minimal invasive procedure.Patients who undergo laparoscopic surgery have a more rapid recovery of bowel function and a shorter hospital stay.The morbidity also is lower,and the rate of disease recurrence is similar compared with open procedures.     

Oncologic outcome of laparoscopic surgery for T1 and T2 colorectal carcinoma

BACKGROUND/AIMS: Laparoscopic surgery for colorectal carcinoma remains controversial because of the technical difficulties and uncertainty regarding the long-term oncologic outcome after laparoscopic surgery. The objective of this study was to evaluate the feasibility for the laparoscopic surgery in the treatment of pT1 and pT2 colorectal carcinoma. METHODOLOGY: A review was performed of a prospective registry of 226 patients who underwent curative laparoscopic resection for pT1 and pT2 colorectal carcinoma between December, 1992 and December, 2001. Patient demographics and outcomes were recorded prospectively. RESULTS: The median follow-up was 43 months. Three patients (2.0%) in the pT1 group and 3 patients (3.9%) in the pT2 group developed recurrence of carcinoma. The expected five-year survival and disease-free survival rates in the pT1 group were 98.9% and 97.6%, respectively, whereas they were 93.6% and 93.4% in the pT2 group. No patient had port-site or peritoneal recurrence during the follow-up period. CONCLUSIONS: The findings of current study demonstrate that oncologic outcome of laparoscopic surgery for patients with pT1 and pT2 colorectal carcinoma appear to be comparable with conventional surgery. Laparoscopic surgery is oncologically appropriate at least for patients with pT1 and pT2 colorectal carcinoma.     

Single center experience of laparoscopic vs. open resection for gastrointestinal stromal tumors of the stomach

BACKGROUND/AIMS: With better understanding of disease biology and technological advances, an increasing number of gastric gastrointestinal stromal tumors (GISTs) are being resected laparoscopically. We assessed our management of gastric GISTs in our institution. METHODOLOGY: Prospectively collected data from 13 patients who underwent surgery for gastric gastrointestinal stromal tumors over an 18-month period were analyzed with respect to operative and oncological outcomes. Seven patients underwent open resection and 6 patients had laparoscopic resection. RESULTS: The tumors were evenly distributed in both groups in whom the median age was 68 years in the open group vs. 70 years in the laparoscopic group. The median operating time was 132 min in the open group and 110 min in the laparoscopic group and patients who had a laparoscopic resection had a shorter hospital stay (4 days versus 11 days). Patients in the open group had a larger tumor the patients in the laparoscopic group (11.5 x 6 x 4 cm vs. 5 x 4 x 3 cm). No patient had evidence of recurrence at median follow-up of 9 months. CONCLUSIONS: Patients with small gastric GISTs can be safely resected with a laparoscopic approach, offering a quicker operation and shorter hospital stay. A laparoscopic approach does not alter risk of early local or distant recurrence.     

Can laparoscopy reduce hospital stay in the treatment of crohn's disease?

PURPOSE: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery. METHODS: Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures). RESULTS: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05). CONCLUSION: There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.     

Laparoscopic and Open Anterior Resection for Upper and Mid Rectal Cancer: An Evaluation of Outcomes

Purpose This study was designed to compare the outcomes of laparoscopic anterior resection with open operation for mid and upper rectal cancer. Methods A total of 265 patients who underwent elective laparoscopic or open anterior resection for cancer of the mid and upper rectum from June 2000 to December 2004 were included. Data about the patients’ demographics, operative details, postoperative outcome, and disease status were collected prospectively. Comparison of the outcome between laparoscopic and open resection was performed. Results The median age of the 265 patients was 69 (range, 27–91) years, and laparoscopic anterior resection was performed in 98 patients (37 percent). There was no difference in the age, gender, comorbidities, and level of tumor between the two groups. The operating time was longer in the laparoscopic group (200 vs. 127 minutes; P < 0.01), but the blood loss was less (200 vs. 250 ml; P = 0.027). The overall operative mortality was 1.8 percent, and the complication rate was 27.9 percent. Significantly more patients with early diseases (Stage I and Stage II) were operated with laparoscopic approach. There was no difference in the mortality or morbidity between the two groups. Anastomotic leakage occurred in five patients with open resection and one with laparoscopic resection (P = 0.418). Patients with laparoscopic resection had an earlier return of bowel function and earlier resumption of diet as well as a shorter median hospital stay (7 vs. 8 days; P < 0.001). With the median follow-up of the surviving patients for 21.2 months, the three-year local recurrence rates for those with open and laparoscopic resection were 4.9 and 3.3 percent, respectively (P = 0.513). In patients with Stage I and Stage II disease, the three-year cancer-specific survivals for open and laparoscopic resection were 89.8 and 88.6 percent, respectively (P = 0.882), whereas those of patients with Stage III disease were 65.6 and 55.5 percent, respectively (P = 0.911). Conclusions Laparoscopic anterior resection for mid and proximal rectal cancer is a safe option with short-term advantages compared with open operation. The oncologic outcomes of patients who underwent laparoscopic anterior resection were not compromised, with similar local recurrence rate and the cancer-specific survival rate as patients who underwent open resection. Presented at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Surgical management of entero and colocutaneous fistulae in Crohn's disease: 17 year's experience

BACKGROUND AND AIMS: Fistulous disease is common in Crohn's disease, and entero- and colocutaneous fistulae are particularly debilitating and difficult to manage. We present the results of surgical management of these fistulas. PATIENTS AND METHODS: Retrospective chart review of all 51 patients with Crohn's disease (56 surgical procedures) undergoing surgery for cutaneous fistulae between 1983 and 2000. RESULTS: Previous surgery for Crohn's disease had been carried out in 43 patients (84%). The fistula site was enterocutaneous in 36 patients (64%), colocutaneous in 12 (21%), and anastomotic in 8 (14%); 9 patients (16%) also had associated enteroenteric fistulas. The onset of the fistula followed abscess drainage in 15 (27%) and occurred at the site of recurrent disease in 41 (73%). Forty patients (71%) initially underwent conservative management prior to surgery; 16 (28%) underwent surgery directly. Surgical procedures were: 25 ileocolic resections, 8 stoma revisions with resection, 8 small bowel resections 7 subtotal colectomies, 4 partial colectomies, 3 proctocolectomies, and one fistula tract excision. Mean total length of stay was 18 days (postoperative 10.7 days). Six (11%) patients had eight postoperative complications. Mean follow-up was 48.6 months (range 3-187). Recurrence as defined by either clinical examination or reoperation was documented in nine fistulas (16%), with a mean time to recurrence of 27 months. CONCLUSION: Entero-and colocutaneous fistulae usually occur from a site of active disease. Surgical management with bowel resection, including the fistula, is the preferred method of treatment. Morbidity has been low and recurrence rate lower than expected.     

Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up

PURPOSE: The role of laparoscopic surgery in the cure of colorectal cancer is controversial. The aim of this study was to evaluate long-term survival after curative, laparoscopic resection of colorectal cancer. Specifically, we wanted to review those patients who now had complete five-year follow-up. METHODS: One hundred two consecutive patients (March 1991 to March 1996) underwent laparoscopic colon resections for cancer at one institution and now have complete five-year survival data. Charts were retrospectively reviewed and results compared with conventional surgery, i.e., open colectomy at our institution, and with the National Cancer Data Base during a similar time period. RESULTS: Fifty-nine male and 43 female patients with an average age of 70 (range, 34-92) years made up the study. Complications occurred in 23 percent of patients, and one patient died (1 percent). Forty-four laparoscopic right colectomies, 2 transverse colectomies, 36 laparoscopic left or sigmoid colectomies, 15 laparoscopic low anterior resections, and 5 laparoscopic abdominoperineal resections were performed. The average number of lymph nodes harvested was 6.6 +/- 0.61 (range, 0-22). Eight cases (7.8 percent) were "converted to open"; i.e., the typical 6-cm extraction site was lengthened to complete mobilization, devascularization, resection, or anastomosis, or a separate incision was required to complete the procedure. There was one extraction-site recurrence and one port-site recurrence; both occurred before the routine use of plastic-sleeve wound protection. The mean follow-up for laparoscopic colon resection patients was 64.4 +/- 2.8 (range, 1-111) months. According to the TNM classification system, 27 patients had Stage I cancer, 37 had Stage II, 23 had Stage III, and 15 had Stage IV. Similar five-year survival rates for laparoscopic and conventional surgery for cancer were noted. The five-year relative survival rates in the laparoscopic colon resection group were 73 percent for Stage I, 61 percent for Stage II, 55 percent for Stage III, and 0 percent for Stage IV. The five-year relative survival rates for the open colectomy and National Cancer Data Base groups were 75 and 70 percent, respectively, for Stage I, 65 and 60 percent for Stage II, 46 and 44 percent for Stage III, and 11 and 7 percent for Stage IV. CONCLUSIONS: Laparoscopic colon resection for cancer is safe and feasible in a private setting. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery. Prospective, randomized trials presently under way will likely confirm these results.     

Laparoscopic resection for diverticular disease

PURPOSE: The role of laparoscopic surgery in treatment of patients with diverticulitis is unclear. A retrospective comparison of laparoscopic with conventional surgery for patients with chronic diverticulitis was performed to assess morbidity, recovery from surgery, and cost. METHODS: Records of patients undergoing elective resection for uncomplicated diverticulitis from 1992 to 1994 at a single institution were reviewed. Laparoscopic resection involved complete intracorporeal dissection, bowel division, and anastomosis with extracorporeal placement of an anvil. RESULTS: Sigmoid and left colon resections were performed laparoscopically in 25 patients and by open technique in 17 patients by two independent operating teams. No significant differences existed in age, gender, weight, comorbidities, or operations performed. In the laparoscopic group, three operations were converted to open laparotomy (12 percent) because of unclear anatomy. Major complications occurred in two patients who underwent laparoscopic resection, both requiring laparotomy, and in one patient in the conventional surgery group who underwent computed tomographic-guided drainage of an abscess. Patients who underwent laparoscopic resection tolerated a regular diet sooner than patients who underwent conventional surgery (3.2±0.9vs.5.7±1.1 days;P<0.001) and were discharged from the hospital earlier (4.2±1.1vs.6.8±1.1 days;P<0.001). Overall costs were higher in the laparoscopic group than the open surgery group ($10,230±49.1vs.$7,068±37.1;P<0.001) because of a significantly longer total operating room time (397±9.1vs.115±5.1 min;P<0.001). Follow-up studies with a mean of one year revealed two port site infections in the laparoscopic group and one wound infection in the open group. Of patients undergoing conventional resection, one patient experienced a postoperative bowel obstruction that was managed nonoperatively, and, in one patient, an incarcerated incisional hernia developed that required urgent laparotomy. CONCLUSIONS: Laparoscopic resection in patients with chronic diverticulitis is safe, with faster recovery and shorter hospital stay compared with conventional open surgery. Higher cost of operating room usage time makes the laparoscopic technique difficult to justify economically. Simplification of operating room use and better case selection may improve cost-effectiveness of the laparoscopic approach.     

Laparoscopic vs. open resection for colorectal adenocarcinoma.

PURPOSE: To compare the outcome after laparoscopic versus open resection for colorectal adenocarcinoma. METHODS: A retrospective cohort analysis of all patients undergoing elective resection for colorectal adenocarcinoma between November 1992 and June 1999 at a university-affiliated hospital. These included 219 open (mean age, 68.3 years) and 98 laparoscopic (mean age, 70.3 years) resections. Data from converted cases (n = 12) were included in the laparoscopic group using the intention-to-treat principle. RESULTS: Operative time, lymph node yield, resection margins and postoperative morbidity and mortality were similar between laparoscopic and open technique. Parenteral analgesic use was less in the laparoscopic group (laparoscopic, 2.7; open, 3.2 days; P = 0.021). Time to first flatus (laparoscopic, 1.8; open, 3 days; P < 0.0001) and first bowel movement (laparoscopic, 3.5; open, 4.9 days; P < 0.0001) was shorter in the laparoscopic group. Resumption of an oral liquid diet (laparoscopic, 2.1; open, 4 days; P < 0.0001) and solid diet (laparoscopic, 5.2; open, 7.1 days; P < 0.0001) was also quicker in the laparoscopic patients. Length of hospitalization was significantly shorter in the laparoscopic patients (laparoscopic, 6.9; open, 10.9 days; P < 0.001). There were less minor complications in the laparoscopic group (laparoscopic, 11.2; open, 21.5 percent; P = 0.029) but no difference in major complications or perioperative mortality. Recurrence, disease-free and overall survival were similar between the two groups. No port site recurrences occurred in the laparoscopic group but there were three wound recurrences in the open group. CONCLUSIONS: Laparoscopic resection for colorectal cancer can be performed safely and effectively in tertiary centers. Earlier discharge from hospital, quicker resumption of oral feeds and less postoperative pain are clear advantages. No adverse effect on recurrence or survival was noted, but results of prospective, randomized trials, currently underway, are needed before laparoscopic resection for colorectal cancer becomes the standard of practice.     

Duration of recurrent ileitis after ileocolonic resection correlates with presurgical extent of Crohn's disease.

Crohn's disease of the terminal ileum recurs in a predictable sequence proximal to the ileocolonic anastomosis after surgical resection. To confirm the suspicion that the duration of recurrent ileitis correlates with the extent of presurgical disease, this study investigated 23 consecutive patients with recurrent Crohn's disease symptoms who had undergone ileocaecal resections between 1982 and 1992 at our institution and had both preoperative and postoperative small bowel follow through studies available for comparison. All films were reviewed by a blinded gastrointestinal radiologist using uniform criteria. Symptomatic recurrence was reported at a mean (SEM) of 29 (25) months after resection. Presurgical length of inflammation averaged 26 (15) (8-57) cm and at recurrence 24 (14) (7-55) cm. The correlation coefficient (r) between pre and postsurgical extent of ileal disease was 0.70 (p < 0.0001). Seven patients had sequential small bowel series after 20 (10) (7-36) months without intervening surgery. The extent of measured inflammation between examinations correlated with r = 0.995 (p < 0.0001), showing the consistency of the measurement process. The close correlation between the duration of postoperative recurrence with the extent of presurgical disease is another example of individual patterns of recurrent Crohn's disease and is an additional factor to be considered when contemplating surgical resections.     

Results of laparoscopic versus open resections for non-early rectal cancer in patients with a minimum follow-up of four years

BACKGROUND/AIMS: Laparoscopic rectal resection for malignancy is still debated. Concern has been expressed regarding the lack of significant data from larger patient series with longer periods of follow-up. The aims of this study were to compare long-term outcome with a minimum follow-up of four years in unselected patients undergoing either laparoscopic rectal resection or open rectal resection for cancer. METHODOLOGY: From May 1992 to August 1997 all electively admitted patients with rectal cancer were included in a prospective non-randomized study. Written information was submitted to each patient and the location in each group (laparoscopic or open) was related to the patient's choice. The inclusion protocol criteria excluded T1 tumors. All 68 T2-T4 patients underwent preoperative radiotherapy (5.040 cGy), completed with chemotherapy in selected cases (patients below 70 years of age). Long-term results were compared between the two groups. Follow-up time of both groups ranged between 48 and 96 months (mean, 49.4 months). RESULTS: Excluding patients who underwent a palliative resection or conversion to open surgery and deaths not related to cancer, 53 pts (29 laparoscopic rectal resection, 24 open rectal resection) out of 68 are available and are the object of this study. No patient was lost to follow-up. No wound recurrence was observed. The local recurrence rate after laparoscopic rectal resection was 24.1% vs. 25% after open rectal resection (P = 0.799). Distant metastases occurred in 20.7% of patients in the LLR group (laparoscopic rectal resection) vs. 25% in the ORR group (open rectal resection) (P = 0.980). Cumulative survival probability after laparoscopic rectal resection and open rectal resection was 0.690 and 0.625 (P = 0.492), respectively. Cumulative survival probability for Duke's stage A, B and C in the LRR group vs. the ORR group was 1.000 vs. 0.900 (P = 0.585), 0.667 vs. 0.636 (P = 0.496) and 0.429 vs. 0.445 (P = 0.501), respectively. Sixteen laparoscopic rectal resection patients (55.2%) and 12 open rectal resection patients (50%) are presently disease free (P = 0.979). CONCLUSIONS: Long-term results after laparoscopic resection of rectal cancer were comparable to those after conventional resection, with a trend in favor of the laparoscopic approach that does not reach a statistically significant difference, possibly due to the limited size of the sample.