Laparoscopic Versus an Open Colectomy in an Emergency Setting: A Case-Controlled Study

PURPOSE: Laparoscopy continues to be increasingly adopted for elective colorectal resections. However, its role in an emergency setting remains controversial. The aim of this study was to compare the outcomes between laparoscopic and open colectomies performed for emergency colorectal conditions. METHODS: A retrospective review of all patients who underwent emergency laparoscopic colectomies for various surgical conditions was performed. These patients were matched for age, gender, surgical diagnosis and type of surgery with patients who underwent emergency open colectomies. RESULTS: Twenty-three emergency laparoscopic colectomies were performed from April 2006 to October 2011 for patients with lower gastrointestinal tract bleeding (6), colonic obstruction (4) and colonic perforation (13). The hand-assisted laparoscopic technique was utilized in 15 cases (65.2%). There were 4 (17.4%) conversions to the open technique. The operative time was longer in the laparoscopic group (175 minutes vs. 145 minutes, P = 0.04), and the duration of hospitalization was shorter in the laparoscopic group (6 days vs. 7 days, P = 0.15). The overall postoperative morbidity rates were similar between the two groups (P = 0.93), with only 3 patients in each group requiring postoperative surgical intensive-care-unit stays or reoperations. There were no mortalities. The cost analysis did not demonstrate any significant differences in the procedural (P = 0.57) and the nonprocedural costs (P = 0.48) between the two groups. CONCLUSION: Emergency laparoscopic colectomy in a carefully-selected patient group is safe. Although the operative times were longer, the postoperative outcomes were comparable to those of the open technique. The laparoscopic group did not incur a higher cost.

Managing Deep Postanal Space Sepsis via an Intersphincteric Approach: Our Early Experience

PURPOSE: Managing deep postanal (DPA) sepsis often involves multiple procedures over a long time. An intersphincteric approach allows adequate drainage to be performed while tackling the primary pathology at the same sitting. The aim of our study was to evaluate this novel technique in managing DPA sepsis. METHODS: A retrospective review of all patients who underwent this intersphincteric technique in managing DPA sepsis from February 2008 to October 2010 was performed. All surgeries were performed by the same surgeon. RESULTS: Seventeen patients with a median age of 43 years (range, 32 to 71 years) and comprised of 94.1% (n = 16) males formed the study group. In all patients, an internal opening in the posterior midline with a tract leading to the deep postanal space was identified. This intersphincteric approach operation was adopted as the primary procedure in 12 patients (70.6%) and was successful in 11 (91.7%). In the only failure, the sepsis recurred, and a successful advancement flap procedure was eventually performed. Five other patients (29.4%) underwent this same procedure as a secondary procedure after an initial drainage operation. Only one was successful. In the remaining four patients, one had a recurrent abscess that required drainage while the other three patients had a tract between the internal opening and the intersphincteric incision. They subsequently underwent a drainage procedure with seton insertion and advancement flap procedures. CONCLUSION: Managing DPA space sepsis via an intersphincteric approach is successful in 70.6% of patients. This single-staged technique allows for effective drainage of the sepsis and removal of the primary pathology in the intersphincteric space.

Factors that Influence on Reliability of 3D-Endorectal Ultrasonography in the Preoperative Staging of Rectal Cancer

Background: Preoperative clinical staging of rectal tumors is very important to allow surgeons make informed decisions about the types of surgeries that should be performed. Endorectal ultrasonography (ERUS) is one of the tools that has been commonly used in clinical staging of rectal tumors. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal tumors and evaluate the factors that influence on the reliability of endorectal ultrasound staging such as experience of ultrasonographer, Characteristics of the tumor and tumor site (in terms of height) Methods: Fifty-three patients with rectal adenocarcinomas underwent an endorectal ultrasonography evaluation during a period of three years. The evaluation was performed by three surgeons. We compared the endorectal ultrasonography staging with the pathology findings based on the surgical specimens. Patients with preoperative chemoradiation were excluded from the study. Results: Overall accuracy in assessing the level of rectal wall invasion was 55%, with 19% of the tumours overstaged and 26% understaged. Accuracy in assessing nodal involvement in 44 patients treated with radical surgery was 45%, with 41% overstaged and 14% understaged. If focus on experience of ultrasonographer that show learning curve for good progression in accuracy of assessing tumor invasion from 42% in 2005 to 87% in 2007. Accuracy for Characteristics of the tumor that show better progression in accuracy for ulcerative tumor from 25% in 2005, 62% in 2006 and 100% in 2007 but for polypoid tumor that show poorer accuracy rate only 50% for all three years. Whether tumour site (in terms of height) found a significantly poorer accuracy rate for tumours of the distal third (2-6 cm from anal verge) that show accuracy only 48% ,on the other hand significantly better for tumours of the middle third (7-12 cm from anal verge) that show accuracy 62%. Accuracy depended on the tumor stage, ultrasonographer experience , characteristics of the tumor and tumor site (in terms of height). Conclusions: The accuracy of endorectal ultrasonography in assessing the depth of tumor invasion, particularly for early cancers, is lower than previously reported. Endorectal ultrasound is more operator dependent and accuracies improve with experience and characteristics of the tumor and tumor site (in terms of height) that influence on the reliability of accuracy.