Does the time from symptom onset to surgery affect the outcomes of patients with acute appendicitis? A prospective cohort study of 255 patients.

INTRODUCTION: The objective of this study was to evaluate the impact of operative timing on outcomes of acute appendicitis. METHODS: This study examined adult patients who had presented to the hospital with acute appendicitis and had undergone appendectomy from December 2017 to February 2019. Time delay and outcomes of perforated and non-perforated appendicitis were compared. Patients were classified into five groups based on the period from symptom onset to operation: group 1, <24 hours; group 2, ≥24 and <48 hours; group 3, ≥48 and <72 hours; group 4, ≥72 and <96 hours; and group 5, ≥96 hours. The five groups were compared, with risk of perforation assessed in particular. RESULTS: A total of 255 patients were included in the analysis. Symptom duration, operative time, and length of postoperative hospital stay (P < .001) were significantly longer in the perforated group (n = 49) than in the non-perforated group (n = 206). The perforated group also had a higher conversion rate to open procedures (P = .002) and a higher rate of wound infection (P = .034). Group 1 had 53 patients, group 2 had 95 patients, group 3 had 57 patients, group 4 had 32 patients, and group 5 had 18 patients. The incidence of appendiceal perforation and median operative time progressively increased along with symptom duration in the five groups. In multivariate analyses, independent risk factors for appendiceal perforation were male gender (odds ratio = 2.33, 95% confidence interval [CI]: 1.07-5.08) and symptom duration ≥48 hours (relative to ≥24 and <48 hours) (odds ratio = 4.64, 95%CI: 1.76-12.27). Patients with symptom duration ≥72 hours had a significantly longer operative time than those with symptom duration ≥48 and <72 hours (ß = 21.38, 95%CI: 5.66-37.11, P = .008). CONCLUSION: The risk of perforation increased significantly 48 hours after the onset of appendicitis. Symptoms duration ≥72 hours was associated with a longer operative time.

Multitask training promotes automaticity of a fundamental laparoscopic skill without compromising the rate of skill learning.

BACKGROUND: A defining characteristic of expertise is automated performance of skills, which frees attentional capacity to better cope with some common intraoperative stressors. There is a paucity of research on how best to foster automated performance by surgical trainees. This study examined the use of a multitask training approach to promote automated, robust laparoscopic skills. METHODS: Eighty-one medical students completed training of a fundamental laparoscopic task in either a traditional single-task training condition or a novel multitask training condition. Following training, participants' laparoscopic performance was tested in a retention test, two stress transfer tests (distraction and time pressure) and a secondary task test, which was included to evaluate automaticity of performance. The laparoscopic task was also performed as part of a formal clinical examination (OSCE). RESULTS: The training groups did not differ in the number of trials required to reach task proficiency (p = .72), retention of skill (ps > .45), or performance in the clinical examination (p = .14); however, the groups did differ with respect to the secondary task (p = .016). The movement efficiency (number of hand movements) of single-task trainees, but not multitask trainees, was negatively affected during the secondary task test. The two stress transfer tests had no discernable impact on the performance of either training group. CONCLUSION: Multitask training was not detrimental to the rate of learning of a fundamental laparoscopic skill and added value by providing resilience in the face of a secondary task load, indicative of skill automaticity. Further work is needed to determine the extent of the clinical utility afforded by multitask training.

Exploring personality dimensions that influence practice and performance of a simulated laparoscopic task in the objective structured clinical examination.

BACKGROUND: Surgical educators have encouraged the investigation of individual differences in aptitude and personality in surgical performance. An individual personality difference that has been shown to influence laparoscopic performance under time pressure is movement specific reinvestment. Movement specific reinvestment has 2 dimensions, movement self-consciousness (MS-C) (i.e., the propensity to consciously monitor movements) and conscious motor processing (CMP) (i.e., the propensity to consciously control movements), which have been shown to differentially influence laparoscopic performance in practice but have yet to be investigated in the context of psychological stress (e.g., the objective structured clinical examination [OSCE]). OBJECTIVE: This study investigated the role of individual differences in propensity for MS-C and CMP in practice of a fundamental laparoscopic skill and in laparoscopic performance during the OSCE. Furthermore, this study examined whether individual differences during practice of a fundamental laparoscopic skill were predictive of laparoscopic performance during the OSCE. METHODS: Overall, 77 final-year undergraduate medical students completed the movement specific reinvestment scale, an assessment tool that quantifies the propensity for MS-C and CMP. Participants were trained to proficiency on a fundamental laparoscopic skill. The number of trials to reach proficiency was measured, and completion times were recorded during early practice, later practice, and the OSCE. RESULTS: There was a trend for CMP to be negatively associated with the number of trials to reach proficiency (p = 0.064). A higher propensity for CMP was associated with fewer trials to reach proficiency (ß = -0.70, p = 0.023). CMP and MS-C did not significantly predict completion times in the OSCE (p > 0.05). Completion times in early practice (ß = 0.05, p = 0.016) and later practice (ß = 0.47, p < 0.001) and number of trials to reach proficiency (ß = 0.23, p = 0.003) significantly predicted completion times in the OSCE. CONCLUSION: It appears that a higher propensity for CMP predicts faster rates of learning of a fundamental laparoscopic skill. Furthermore, laparoscopic performance during practice is indicative of laparoscopic performance in the challenging conditions of the OSCE. The lack of association between the 2 dimensions of movement specific reinvestment and performance during the OSCE is explained using the theory of reinvestment as a framework. Overall, consideration of personality differences and individual differences in ability during practice could help inform the development of individualized surgical training programs.

Conscious motor processing and movement self-consciousness: two dimensions of personality that influence laparoscopic training.

BACKGROUND: Identifying personality factors that account for individual differences in surgical training and performance has practical implications for surgical education. Movement-specific reinvestment is a potentially relevant personality factor that has a moderating effect on laparoscopic performance under time pressure. Movement-specific reinvestment has 2 dimensions, which represent an individual's propensity to consciously control movements (conscious motor processing) or to consciously monitor their 'style' of movement (movement self-consciousness). OBJECTIVE: This study aimed at investigating the moderating effects of the 2 dimensions of movement-specific reinvestment in the learning and updating (cross-handed technique) of laparoscopic skills. METHODS: Medical students completed the Movement-Specific Reinvestment Scale, a psychometric assessment tool that evaluates the conscious motor processing and movement self-consciousness dimensions of movement-specific reinvestment. They were then trained to a criterion level of proficiency on a fundamental laparoscopic skills task and were tested on a novel cross-handed technique. Completion times were recorded for early-learning, late-learning, and cross-handed trials. RESULTS: Propensity for movement self-consciousness but not conscious motor processing was a significant predictor of task completion times both early (p = 0.036) and late (p = 0.002) in learning, but completion times during the cross-handed trials were predicted by the propensity for conscious motor processing (p = 0.04) rather than movement self-consciousness (p = 0.21). CONCLUSION: Higher propensity for movement self-consciousness is associated with slower performance times on novel and well-practiced laparoscopic tasks. For complex surgical techniques, however, conscious motor processing plays a more influential role in performance than movement self-consciousness. The findings imply that these 2 dimensions of movement-specific reinvestment have a differential influence in the learning and updating of laparoscopic skills.

Colorectal resection after stent insertion for obstructing cancer: comparison between open and laparoscopic approaches.

AIM: To evaluate surgical outcomes after stent insertion for obstructing colorectal malignancy and to compare between laparoscopic and open approach. METHODS: Surgical resection was performed after stent insertion for malignant colorectal obstruction in 36 patients with a median age of 73 years. Eighteen patients were treated with open resection, whereas 18 underwent a laparoscopic resection. The outcomes were evaluated and comparison was made between patients with laparoscopic and open resection. RESULTS: The mean interval between stent insertion and surgery was 11 days. One patient died within 30 days (2.8%). The overall incidence of postoperative morbidity was 22% and reoperation was required in 3 patients (8.8%). The median postoperative hospital stay was 8.5 days for the open surgery group and 5.5 days for the laparoscopic group (P = 0.004). The postoperative morbidity rates for the open and laparoscopic groups were 33.3% and 11.1%, respectively (P = 0.228). In those patients with nonmetastatic disease, with the median follow-up of 20 months, the 5-year survival rate was 49.5%. CONCLUSIONS: Our experience showed that after successful endoscopic stent insertion for malignant colorectal obstruction, elective surgical resection could be performed safely. The combined endoscopic and laparoscopic procedure provides a less invasive alternative to the multistage open operations and is feasible for patients with obstructing colon cancer.

Single-incision versus conventional laparoscopic colectomy for colonic neoplasm: a randomized, controlled trial.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) is a newly developed procedure with the benefit of better cosmetic outcome and potentially reduced wound pain compared with conventionally laparoscopic colectomy (CLC). However, the application of SILC requires careful evaluation to prove its benefit and safety. This randomized, controlled study compared the operative outcome of patients who underwent SILC and CLC. METHODS: Patients who had small cancer (<4 cm) or adenomatous polyp requiring colectomy were randomized to have SILC or CLC. The patients were blinded to the procedures and the postoperative pain was used as the primary outcome measure. All patients had patient-controlled analgesia with intravenous morphine after the operation and the nominal rating score on days 1-3 and day 14 were recorded by research staff, who did not known the types of operations. Other operative outcomes of the two groups of patients also were recorded prospectively and compared. RESULTS: There were 25 patients in each group. The patients' demographics, tumor characteristics, operating time, blood loss, complication rate, number of lymph nodes harvested, and resection margin have no statistically significant difference between the two groups. There was no operative mortality in both groups. The SILC group had consistently lower median pain score than CLC group in the whole postoperative course and the difference was statistically significant on day 1 (0 (0-5) vs. day 3 (0-6) respectively; p = 0.002) and day 2 (0 (0-3) vs. 2 (0-8) respectively; p = 0.014). The median hospital stay in the SILC group also was shorter the CLC group. CONCLUSIONS: In a selected group of patients with small tumor and good operative risk, SILC is a safe alternative to CLC. Single-port laparoscopic colectomy also is associated with the benefits of less postoperative pain and shorter hospital stay than CLC.

Survival following laparoscopic versus open resection for colorectal cancer.

BACKGROUND: This study aimed to compare the overall and disease specific survivals of patients who underwent laparoscopic and open resection of colorectal cancer in a high volume tertiary center. METHODS: Consecutive patients who underwent elective resection for colorectal cancer (open resection, n = 1,197; laparoscopic resection, n = 814) from January 2000 to December 2009 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. RESULTS: The age, gender, medical morbidity, and American Society of Anesthesiologists status were similar in the two groups. Laparoscopic resection was associated with significantly less blood loss and a shorter hospital stay. The operating mortality and morbidity were significantly lower in the laparoscopic group. The qualities of the specimens in terms of the distal resection margin and the number of lymph nodes examined were not inferior in the laparoscopic group. With the median follow-up of 40.3 months, the 5-year overall survival (74.1% vs. 65.5%, p < 0.001) and disease specific survival (81.9% vs. 75.2%, p = 0.002) were significantly better in patients with non-disseminated disease in the laparoscopic group. The operative approach was an independent prognostic factor in the overall (risk ratio 1.36, 95% CI 1.093-1.700, p = 0.006) and disease specific (risk ratio 1.32, 95% CI 1.005-1.738, p = 0.048) survivals in multivariate analysis. CONCLUSION: Laparoscopic resection for colorectal cancer is associated with more favorable overall and disease specific survivals when compared with open resection in a high volume tertiary center.

Outcome of laparoscopic resection for colorectal cancer in patients with high operative risk.

BACKGROUND: There is general concern that high-risk patients are more susceptible to the adverse effect of pneumoperitoneum and they are often denied laparoscopic surgery. This study investigated the impact of laparoscopic colorectal cancer resection for patients with high operative risk, which was defined as American Society of Anesthesiologist classes 3 and 4. METHODS: Three hundred thirty-five consecutive high-risk patients who had colorectal cancer resection by open or laparoscopic surgery were included. The patient and tumor characteristics and operative outcomes were recorded prospectively, and comparison was made between the two groups. RESULTS: Compared to open surgery, patients with laparoscopic resection had a shorter hospital stay (8 [6-12] vs. 6 [4-9] days; P < 0.001), less blood loss (200 [100-400] vs. 140 [80-250] mL; P = 0.006), reduced cardiac complication rate (13.2% vs. 3.7%; P = 0.006), overall operative complication rate (36.6% vs. 21.3%; P = 0.006), and a trend toward a lower mortality rate (4.4% vs. 0.9%; P = 0.083). There was no difference in 3-year overall and disease-free survival between two groups. Operative blood loss (P = 0.035; odds ratio = 2.69; 95% confidence interval, 1.00-6.78) and open surgery (P = 0.007; odds ratio = 2.31; 95% confidence interval, 1.26-4.23) were independent factors for occurrence of complication. CONCLUSIONS: Laparoscopic colorectal cancer resection is associated with more favorable short-term results and should be recommended as the preferred treatment option for high-risk patients.

Enhanced recovery program in laparoscopic colectomy for cancer.

INTRODUCTION: Both laparoscopic colectomy and application of enhanced recovery program (ERP) in open colectomy have been demonstrated to enable early recovery and to shorten hospital stay. This study evaluated the impact of ERP on results of laparoscopic colectomy and comparison was made with the outcomes of patients prior to the application of ERP. METHODS: An ERP was implemented in the authors' center in December 2006. Short-term outcomes of consecutive 84 patients who underwent laparoscopic colonic cancer resection 23 months before (control group) and 96 patients who were operated within 13 months; after application of ERP (ERP group) were compared. RESULTS: Between the ERP and control groups, there was no statistical difference in patient characteristics, pathology, operating time, blood loss, conversion rate or complications. Compared to the control group, patients in the ERP group had earlier passage of flatus [2 (range: 1-5) versus 2 (range: 1-4) days after operation respectively; p = 0.03)] and a lower incidence of prolonged post-operative ileus (6% versus 0 respectively; p = 0.02). There was no difference in the hospital stay between the two groups [4 (range: 2-34) days in control group and 4 (range: 2-23) days in ERP group; p = 0.4)]. The re-admission rate was also similar (7% in control group and 5% in ERP group; p = 0.59). CONCLUSIONS: In laparoscopic colectomy for cancer, application of ERP was associated with no increase in complication rate but significant improvement of gastrointestinal function. ERP further hastened patient recovery but resulted in no difference in hospital stay.

Single-incision laparoscopic colectomy: early experience.

PURPOSE: Single-incision laparoscopic surgery was developed recently and has the benefit of reducing the number of incisions. Its application in colectomy has been published only in case reports. The present study evaluated our early results of single-incision laproscopic surgery in a series of 8 patients who underwent colectomy for various colorectal pathologies. METHODS: Eight patients underwent single-incision laparoscopic colectomy for cancer (n = 5), polyps (n = 2), and diverticulitis (n = 1) during the study period. The data on the operations and outcomes were collected prospectively and analyzed. RESULTS: The median age of the patients was 78 years (range, 49-88). The operations were right colectomy (n = 6), left colectomy (n = 1), and anterior resection (n = 1). The median operating time was 175 minutes (range, 103-260) and the median blood loss was 55 mL (range, 20-200). The average length of the incision was 3.4 cm (range, 3.0-5.0). One patient required conversion to hand-assisted laparoscopy with a 5-cm incision. The median hospital stay was 3.5 days (range, 3-6) and 1 patient had ileus after the operation. There was no mortality and no reintervention within 30 days. In patients with cancer, all of the resection margins were clear. The median number of lymph nodes examined was 13.5 (range, 9-36). CONCLUSIONS: Single-incision laparoscopic surgery can be applied to colectomy safely. Oncologic resection similar to conventional laparoscopy can be performed with this technique. Further studies are needed to evaluate the outcomes against those of conventional laparoscopic resection.

Multimodality minimally invasive autopsy--a feasible and accurate approach to post-mortem examination.

BACKGROUND: Autopsy examination has been the bedrock of western medicine. With the decline in the autopsy rate secondary to the negative psychological impact to the deceased's relatives, the benefits of autopsy have been undermined. Minimally invasive autopsy has been introduced but has not been widely adopted as an alternative to the 'traditional' open approach. This technique not only provides information on the cause of death abut also minimizes the disfigurement induced to the deceased. Our study aims to explore the feasibility and evaluate the accuracy of this technique. METHODS: A series of coroner cases ordered for autopsy were examined by a group including an experienced forensic pathologist and two experienced laparoscopic surgeons using thoracoscopic, laparoscopic, endoluminal or endovascular approaches. The procedure was video-recorded and the provisional diagnoses and causes of death were made based on the findings. These findings were subsequently correlated with the full autopsy examination. A few limited clinical post-mortem examinations were also performed with consent from relatives. RESULTS: A total of 22 cases of minimally invasive autopsies were performed from November 2007 to March 2008. The median duration of the procedures was 78.3+/-20.7 min. Thoracoscopies and laparoscopies were performed in 18 patients while additional arterioscopic examination with endoscope was performed in two patients with suspected aortic diseases. Four consented limited clinical autopsies were also performed: two of them involved thoracoscopic biopsies of lung tissues, one was a para-mortem upper endoscopy for the investigation of pathology of the stomach and the other one was laparoscopy for a patient, who died of unexplained acidosis. Comparison with full autopsies showed that the accuracy of the diagnosis was 94.4%, the sensitivity was 90%, the specificity was 100%, the positive predictive value was 100% and the negative predictive value was 88.9%. CONCLUSION: Minimally invasive autopsy is a feasible approach, yielding accurate findings when compared with conventional autopsies. The former can be a valuable tool for obtaining more valuable information in situations when the next-of-kin of the deceased does not consent to a conventional autopsy.

A rare complication of laparoscopic low anterior resection.

We report a 70-year-old lady who suffered from carcinoma of rectum with the lowest border of the tumor at 5 cm from the anal verge. Preoperative staging did not show any distant metastasis. Laparoscopic low anterior resection with total mesorectal excision was performed. The rectum was transected with endoscopic stapler and a double stapling anastomosis with a circular stapler was attempted. The spear of the circular stapler pierced through the rectal stump and attempt to remove the spear by pulling the suture attached to the spear failed. A pair of strong laparoscopic forceps was used in an attempt to remove the spear. The spear broke during the attempt of removal. The stapler was withdrawn through the anus with a pair of laparoscopic forceps following it. A new circular stapler was used and the tip was tied to a suture and cotton tape. The pair of forceps, which was still at the anus, was used to pull the cotton tape and the suture through the original perforation at the rectal stump. The tip of the spear of the new stapler was guided through the original perforation of the rectal stump. Double stapling was then performed and the patient recovered uneventfully. This case showed that stapler complication in laparoscopic surgery could be salvaged without conversion.

Impact of the standardized medial-to-lateral approach on outcome of laparoscopic colorectal resection.

BACKGROUND: Beginning in 2004, a standardized medial-to-lateral approach was adopted in laparoscopic colorectal resection (LapCR) in our institution. The present study aimed to compare the outcomes of patients operated on by this approach with those who were operated on prior to the adoption of this technique. METHODS: Data were retrieved from a prospectively collected database on LapCR. The control group included 196 patients operated on from January 2002 to December 2003 and the medial approach group included 224 patients who underwent operations from January 2005 to December 2007. The patient characteristics, operative details, pathology, and surgical outcomes of the two groups were compared. RESULTS: The patient demographics, types of operation and pathology did not show any statistically significant difference. The medial approach group was associated with significantly less median blood loss [100 (interquartile range [IQR]: 50-174) ml versus 150 (IQR:100-300) ml; p < 0.001], shorter hospital stay [4 (IQR: (4-7) versus 7 (5-9) days; p < 0.001], and more lymph nodes harvested [12 (7-17.5) versus 10 (6-15); p = 0.001]. Significantly earlier bowel function recovery was observed in the medial approach group. The mortality and complications did not show any difference. CONCLUSIONS: A standardized medial-to-lateral approach for LapCR is associated with less blood loss, earlier return of bowel function, shorter hospital stay, and increased number of lymph nodes harvested. This should be the preferred approach in LapCR.

Transrectal intraperitoneal assess with transanal endoscopic operation (TEO) device in pig model.

BACKGROUND: Gaining peritoneal access with subsequent safe closure is a prerequisite for natural orifice translumenal surgery (NOTES). We explored the possibility of transanal endoscopic operation (TEO) device to perform transrectal peritoneoscopy in a pig model. OBJECTIVE: Performing transrectal peritoneoscopy with TEO device in pig model. METHODS: Two pigs were used for transrectal peritoneoscopy. A 40-mm rectoscope was inserted via the anus after the induction of general anesthesia. Proctotomy was then created with diathermy and the endoscope was passed through the pararectal space into the peritoneal cavity. Proctotomy was closed with absorbable suture after completion of peritoneoscopy. RESULTS: Completion of the procedures was achieved in 2 pigs. Both pigs survived for more than 30 days. Necropsy revealed completely healed rectum with no evidence of leakage or abscess formation. Adhesions around the colostomy site were minimal. CONCLUSIONS: In conclusion, incorporation of TEO system is safe and useful in animal model for creation and closure of proctotomy for natural orifice translumenal surgery in transrectal access, further experiment should be performed to validate the possibility of application in human. Potential complications need to be addressed and well documented.

Systemic inflammatory response after natural orifice translumenal surgery: transvaginal cholecystectomy in a porcine model.

OBJECTIVE: We analyzed circulating TNF-alpha and IL-6 to determine systemic inflammatory responses associated with transvaginal cholecystectomy in a porcine model. METHODS: Six female pigs were used for a survival study after transvaginal cholecystectomy (NOTES group) using endoscopic submucosal dissection (ESD) instruments and a single-channel endoscope. Blood was drawn preoperatively and 24 hours and 48 hours postoperatively. Four pigs were used as controls. In addition, laparoscopic cholecystectomy was performed in 2 pigs for laparoscopic control. RESULTS: In all 6 pigs in the NOTES group, no major intraoperative complications occurred. No significant differences were found between control, laparoscopic, and NOTES groups in terms of preoperative IL-6 level (P=0.897) and at 24 hours (P=0.790), and 48 hours postoperatively (P=0.945). Similarly, there was no significant difference in mean preoperative (P=0.349) and mean day 2 postoperative TNF-alpha levels (P=0.11). But a significant increase in day 1 postoperative TNF-alpha levels in the laparoscopic group compared with that in the control and NOTES groups was observed (P=0.049). One limitation of our study is that the sample size was relatively small. CONCLUSION: NOTES is safe in animal models in terms of anatomical and cellular level changes with minimal systemic inflammatory host responses elicited. Further study needs to be carried out in humans before NOTES can be recommended for routine use.

Comparison of outcome of open and laparoscopic resection for stage II and stage III rectal cancer.

BACKGROUND: Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. MATERIALS AND METHODS: Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. RESULTS: The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339-0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. CONCLUSIONS: Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.

Impact of laparoscopic colorectal resection on surgical site infection.

OBJECTIVES: This study aimed to identify the risk factors of surgical site infection (SSI) in elective colorectal resection and the strategy for prevention of SSI in modern era of colorectal surgery. BACKGROUND: The practice of colorectal surgery has undergone remarkable evolution recently because of application of laparoscopic resection. This could affect SSI in colorectal patients. An updated investigation of SSI under current practice of colorectal surgery would provide valuable information. METHODS: This was a prospective study of SSI on 1011 patients, who had elective colorectal resection in a university teaching hospital, during January 2002 to December 2006. Standard definition and postoperation follow-up of SSI were adopted through collaboration between surgeons and wound surveillance program of Infection Control Unit. Risk factors of SSI were evaluated. Logistic regression was used to perform multivariate analysis and decide independent risk factors of SSI. RESULTS: The overall rate of incisional SSI and organ/space SSI was 4.8% and 1.7%, respectively. Rate of incisional SSI in open and laparoscopic colorectal resection was 5.7% and 2.7%, respectively. Anastomotic leakage was the only factor that predicted organ/space SSI (P < 0.01). Independent risk factors of incisional SSI included blood transfusion [P = 0.047; odds ratio (OR) = 2.43; 95% confidence interval (CI): 1.0-5.9], anastomotic leakage (P < 0.01; OR = 6.5; 95% CI: 2.3-18.6), and open colorectal resection (P = 0.037; OR = 2.36; 95% CI: 1.1-5.3). CONCLUSION: In current practice of colorectal surgery, operative factors are more important than patient factors for SSI. Good surgical technique to reduce anastomotic leakage and reduce blood transfusion has paramount importance in SSI prevention. Laparoscopic surgery was associated with reduction of rate of SSI by more than 50% when compared with open surgery and would have a strong impact on the prevention of surgical infection.

Laparoscopic bowel resection in the setting of metastatic colorectal cancer.

BACKGROUND: This study aimed to review the outcomes of laparoscopic colorectal resection for patients with stage IV colorectal cancer. METHODS: From the prospectively collected database for patients who underwent surgery for colorectal cancer in our institution, those with stage IV colorectal cancer who underwent elective resection of tumor during the period from January 2000 to June 2006 were included. The outcomes of those with laparoscopic resection were reviewed and comparison was made between patients with laparoscopic and open resection. RESULTS: A total of 200 patients (127 men) with median age of 69 years (range: 25-91 years) were included, and 77 underwent laparoscopic resection. Conversion was required in ten patients (13.0%) and all except one conversion were due to fixed or bulky tumors. There was no operative mortality in the laparoscopic group. The complication rate was 14% and the median postoperative hospital stay was 7 days. When patients with laparoscopic resection were compared with those with open operations, there was no difference in age, gender, comorbidity, or tumor size between the two groups. However, the complication rate was significantly lower in those with laparoscopic resection (14% versus 32%, P = 0.007) and the median hospital stay was significantly shorter (7 days versus 8 days, P = 0.005). The operative mortalities and the survivals were similar in the two groups. CONCLUSIONS: Colorectal resection can be performed safely in patients with stage IV colorectal cancer. The operative outcomes in terms of complication rate and hospital stay compare favorably with patients with open resection.

Impact of conversion on the long-term outcome in laparoscopic resection of colorectal cancer.

BACKGROUND: Long-term outcome of patients with conversion following laparoscopic resection of colorectal cancer has seldom been reported. This study aimed to evaluate the impact of conversion on the operative outcome and survival of patients who underwent laparoscopic resection for colorectal malignancy. METHODS: An analysis of a prospectively collected database of 470 patients who underwent laparoscopic colectomy between May 2000 and December 2006 was performed. The operative results and long-term outcomes of patients with conversion were compared with those with successful laparoscopic operations. RESULTS: The overall conversion rate to open surgery was 8.7% (41 patients). There was no difference in age, comorbid illness, location of tumor, and stage of disease between the laparoscopic and conversion groups. The most common reasons for conversion include adhesions (34.1%), tumor invasion into adjacent structures (17.1%), bulky tumor (9.8%), and uncontrolled hemorrhage (9.8%). A male preponderance was observed in the conversion group. Tumor size was significantly larger in the conversion group compared with the laparoscopic group (5 versus 4 cm, P = 0.002). Although there was no difference in the operative time between the two groups, increased perioperative blood loss (461.9 vs. 191.2 ml, P < 0.001), increased postoperative complication rate (56.1% versus 16.7%, P = 0.001) and prolonged median hospital stay (10 versus 6 days, P < 0.001) were associated with the conversion group. Consequently, patients in the conversion group were more likely to develop local recurrence (9.8% versus 2.8%, P < 0.001) with a significantly reduced cumulative cancer-free survival. CONCLUSION: The disease-free survival and the local recurrence were significantly worse by the presence of conversion in laparoscopic resection for colorectal malignancy. Adoption of a standardized operative strategy may improve the perioperative outcome after conversion.