Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection.
This ...retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak.
Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale.
The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.
Background
Studies focused on postoperative outcome after oncologic right colectomy are lacking. The main objective was to determine pre-/intraoperative risk factors for anastomotic leak after ...elective right colon resection for cancer. Secondary objectives were to determine risk factors for postoperative morbidity and mortality.
Methods
Fifty-two hospitals participated in this prospective, observational study (September 2011–September 2012), including 1102 patients that underwent elective right colectomy. Forty-two pre-/intraoperative variables, related to patient, tumor, surgical procedure, and hospital, were analyzed as potential independent risk factors for anastomotic leak and postoperative morbidity and mortality.
Results
Anastomotic leak was diagnosed in 93 patients (8.4 %), and 72 (6.5 %) of them needed radiological or surgical intervention. Morbidity, mortality, and wound infection rates were 29.0, 2.6, and 13.4 %, respectively. Preoperative serum protein concentration was the only independent risk factor for anastomotic leak (
p
< 0.0001, OR 0.6 per g/dL). When considering only clinically relevant anastomotic leaks, stapled technique (
p
= 0.03, OR 2.1) and preoperative serum protein concentration (
p
= 0.004, OR 0.6 g/dL) were identified as the only two independent risk factors. Age and preoperative serum albumin concentration resulted to be risk factors for postoperative mortality. Male gender, pulmonary or hepatic disease, and open surgical approach were identified as risk factors for postoperative morbidity, while male gender, obesity, intraoperative complication, and end-to-end anastomosis were risk factors for wound infection.
Conclusions
Preoperative nutritional status and the stapled anastomotic technique were the only independent risk factors for clinically relevant anastomotic leak after elective right colectomy for cancer. Age and preoperative nutritional status determined the mortality risk, while laparoscopic approach reduced postoperative morbidity.
PURPOSE:
METHODS:
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:
Background
The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral ...duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer.
Methods
First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital.
Results
The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120–380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9–39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4–20) days. Median follow-up time was 28 (16–41) months. Local and distal recurrence rate was 0.
Conclusion
The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons.
BACKGROUND:TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk ...factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN).
OBJECTIVE:The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection.
DESIGN:This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement.
SETTINGS:The study was conducted in a specialized colorectal unit of a tertiary hospital.
PATIENTS:A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993–2010) were included, and patients with metastasis were excluded.
MAIN OUTCOME MEASURES:A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival.
RESULTS:A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38–100 mo). For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse disease-free survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with ≥12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse disease-free (p = 0.009) and cancer-specific survival (p = 0.014).
LIMITATIONS:This was a retrospective, single-center study.
CONCLUSIONS:pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at http://links.lww.com/DCR/A926.
Purpose
The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome in elderly patients.
Methods
A series of 535 patients with ...colorectal disease who had been randomly assigned to laparoscopic (n = 268) or open (n = 267) resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4 percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge.
Results
Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic and open groups (
P
= 0.0001). In the open group, elderly patients had higher morbidity rate (37.5
vs.
23.9 percent;
P
= 0.02) and longer length of hospital stay (13
vs.
10.6;
P
= 0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2
vs.
15.1 percent) and length of hospital stay (9.5
vs.
9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2
vs.
37.5 percent;
P
= 0.01) and length of hospital stay (9.5
vs.
13;
P
= 0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate (15.1
vs.
23.9 percent;
P
= 0.06) and length of stay (9.1
vs.
10.6;
P
= 0.004) were less pronounced.
Conclusions
Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery.
Aim
The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to ...show SFM approaches in an easy and practical way to make it easy to learn and teach.
Methods
Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM.
Results
First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure “Box”(SFBox).
Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access.
Conclusion
With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure “Box” is a useful way to learn and teach this surgical maneuver.
This study was designed to evaluate long-term complications, quality of life, and survival rate in a series of colorectal cancer patients randomized to laparoscopic or open surgery.
A total of 391 ...patients with colorectal cancer were randomly assigned to laparoscopic (n = 190) or open (n = 201) resection. Long-term follow-up was performed every six months by office visits. Quality of life was assessed at 12, 24, and 48 months after surgery by a modified version of Short Form 36 Health Survey questionnaire. All patients were analyzed on an intention-to-treat basis.
Eight (4.2 percent) laparoscopic group patients needed conversion to open surgery. Overall long-term morbidity rate was 6.8 percent (13/190) in the laparoscopic vs. 14.9 percent (30/201) in the open group (P = 0.018). Overall quality of life was significantly better in the laparoscopic group in the first 12 months after surgery, whereas at 24 months, patients of the laparoscopic group reported a significant advantage only in social functioning. No difference was found in both overall and disease-free survival rates by comparing laparoscopic vs. open group.
Laparoscopic colorectal resection was associated with a lower incidence of long-term complications and a better quality of life in the first 12 months after surgery compared with open surgery. No difference between groups was found in overall and disease-free survival rates.
...it appears essential to classify tumors based on the underlying oncogenic pathways and to develop biological as well as genotype-based molecular therapies acting on individual tumors, redefining ...deeply the natural history of the colorectal cancer and establishing a new standard for diagnostic, stadiative, and therapeutic tools. X. He and colleagues performed a retrospective analysis to investigate the impact of tumor location on survival outcomes in a total of 377,849 colon cancer patients. Interestingly, they found that the mean time to recurrence was significantly longer in the elevated expression group, concluding that COX-2 expression was an independent factor associated with late recurrence (>3 years after surgery) during the follow-up period after surgery. ...the positive COX-2 patients should be considered candidates for more frequent testing after 3 years of follow-up and extend follow-up period longer than 5 years after surgery.
Purpose
The superior right colic vein (SRCV) has been proposed as the main cause of superior mesenteric vein bleeding by avulsion during laparoscopic right hemicolectomy. Our objective is to identify ...the main vessel causing transverse mesocolic tension during the extraction of the surgical specimen or extracorporeal anastomosis and to perform an anatomical description of the SRCV.
Methods
In this cadaveric study, we performed a simulation of right hemicolectomy and anatomical description of the surgical area of the gastrocolic trunk of Henle (SAGCTH), the gastrocolic trunk of Henle (GCTH), and SRCV. The length of the exteriorization of the anastomotic transverse colon (ATC) was measured before and after sectioning the vascular vessel causing the exteriorization tension.
Results
Five fresh cadavers and 12 formalin were dissected. In 100% of the specimens, the SRCV was present and drained in 95% into the GCTH and in 5% directly into the superior mesenteric vein (SMV). In 100% of the specimens, the SRCV caused the tension when extracting the ATC. The mean length of exteriorization of the ATC before and after SRCV section was 7.2 and 10.4 cm in formalin cadavers, meaning a 44% of increment in the length of exteriorization. In fresh cadavers, the mean length of exteriorization increased to 2.7 cm, meaning a 28% of the initial length of exteriorization.
Conclusions
The SRCV is the main cause of tension in the extraction of the surgical specimen after right hemicolectomy. Its high tie increases the length of the ATC exteriorization, in about 3 cm, and could reduce the risk of SMV bleeding during laparoscopic right hemicolectomy and facilitate an extracorporeal anastomosis free of tension.
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