Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study of anastomotic complications.

PURPOSE: Laparoscopic right hemicolectomy (LRH) can be performed with an intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA). It is not clear which technique is best. This study evaluated the impact of each anastomosis technique on perioperative safety and postoperative evolution. METHODS: We performed a retrospective study at a tertiary colorectal surgery center. All patients who had an elective LRH from 2015 to 2019 were analyzed according to the anastomosis technique used. RESULTS: In total, 285 patients were included in the study. IA was performed in 64 patients (22.5%). Mean operative time was longer in the patients with IA (IA, 160±31 minutes vs. EA, 138±42 minutes; P<0.001). No differences were observed in intraoperative complications, time to first bowel movement, length of stay, reoperation, or rehospitalization. Time to first flatus was longer in the patients with IA (P=0.049). At 30 days after surgery, there were no differences in the frequency of anastomotic leak (IA, 0% vs. EA, 2.3%; P=0.59), bleeding (IA, 3.1% vs. EA, 2.7%; P>0.99), or intraabdominal abscess (IA, 0% vs. EA, 0.5%; P>0.99). During follow-up, we noted more incisional hernias in patients with EA (IA, 1.6% vs. EA, 11.3%; P=0.01) and a trend toward more hernia in patients with EA in multivariate analysis (hazard ratio, 7.13; P=0.06). Anastomosis technique had no influence on recurrence. CONCLUSION: For LRH, both IA and EA are safe, with a low incidence of complications when performed by experienced surgeons. IA may be associated with a lower incidence of incisional hernia.

Prophylactic retromuscular mesh placement for parastomal hernia prevention: a retrospective cohort study of permanent colostomies and ileostomies.

PURPOSE: Parastomal hernia (PSH) is the most common complication of stoma formation. The safety and efficiency of prophylactically placing mesh to prevent PSH remain controversial. To address this question, we examined the incidence of clinical and radiological PSH when using parastomal prophylactic mesh (PPM). METHODS: We performed a retrospective, single-center, cohort study that included all patients with permanent stoma creation between 2015 and 2018. Patients were divided into two groups according to the utilization of PPM or not. RESULTS: During the study period, 185 patients had a permanent stoma created, 144 with colostomy and 41 with ileostomy. PPM was placed in 79 patients. There was no difference in the need for early surgical reintervention (p = 0.652) or rehospitalization (p = 0.314) for stoma-related complications in patients with mesh as compared with patients without. Similarly, there was no difference in operative time (p = 0.782) or in length of hospital stay (p = 0.806). No patients experienced infection of the mesh or required prosthesis removal. There was a lower incidence rate of PSH with PPM placement in patients with permanent colostomy [adjusted hazard ratio (HR) 0.50 (95% confidence interval 0.28-0.89); p = 0.018]. In contrast, a higher incidence rate of PSH was observed in patients with ileostomy and PPM [adjusted HR 5.92 (95% confidence interval 1.07-32.65); p = 0.041]. CONCLUSION: Parastomal prophylactic mesh placement to prevent PSH is a safe and efficient approach to reduce the incidence of PSH in patients requiring a permanent colostomy. However, mesh may increase the rate of PSH after permanent ileostomy.

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period.

BACKGROUND: Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era. METHODS: We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS. RESULTS: Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028). CONCLUSION: From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study.

BACKGROUND: We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission. METHODS: Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality. RESULTS: From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs. 32.6%; P = .02), time to oral intake shorter (3 vs. 6 days; P < .01), and LOS shorter (5 vs. 8 days; P = .05) for LCR. CONCLUSIONS: In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.

Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis.

BACKGROUND: Turnbull-Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull-Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis. METHODS: We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality. RESULTS: Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred. CONCLUSION: Salvage Turnbull-Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon's armamentarium as an alternative to the creation of a permanent stoma.

CONTEXTE: La résection colique abdominale avec extraction trans-anale et anastomose colo-anale différée (CAD) fut décrite initialement par Turnbull et Cutait en 1961. Cette intervention a récemment été rapportée pour le traitement des conditions colorectales complexes. Nous avons revu notre expérience avec la CAD comme chirurgie de sauvetage dans le traitement des complications complexes de l'anastomose colo-anale de première intention. MÉTHODES: Nous avons effectué une étude de cohorte rétrospective entre octobre 2010 et septembre 2011, en analysant la morbidité et la mortalité postopératoires. RÉSULTATS: Sept CAD ont été réalisées en raison de complications anastomotiques (3 fuites anastomotiques chroniques, 2 fistules rectovaginales, 1 fistule colovésicale, 1 ischémie colique) résultant du traitement chirurgical d'un cancer rectal. Six patients avaient subi une iléostomie de dérivation pour fuite anastomotique, dans la période précédant la CAD de sauvetage. À l'exception d'un patient, toutes les procédures se sont soldées en succès. Aucune fuite anastomotique n'a été observée après CAD. Un patient a dû subir une résection abdominopérinéale avec colostomie terminale permanente en raison d'ischémie colique aigue du colon distal après CAD. Aucun décès n'est survenu dans les 30 jours suivant la CAD. CONCLUSION: La CAD de sauvetage apparait comme une intervention sécuritaire qui représente une option thérapeutique valable pour les patients souffrant de complications complexes de fuites anastomotiques colorectales. Cette intervention pourrait s'ajouter à l'arsenal du chirurgien comme alternative à la création d'une stomie permanente.

Laparoscopic emergency surgery for diverticular disease that failed medical treatment: a valuable option? Results of a retrospective comparative cohort study.

BACKGROUND: Laparoscopic surgery has become the standard of treatment for elective management of diverticular disease. However, its use in the acute setting remains controversial. OBJECTIVE: The aim of this study is to compare the outcomes of laparoscopic surgery with open surgery in the acute management of complicated diverticular disease that failed initial medical treatment. SETTINGS: This is a single-center comparative retrospective cohort study. PATIENTS: Patients undergoing surgery for complicated diverticular disease after an attempt at medical treatment from 2000 to 2011 were selected. INTERVENTION: Laparoscopic versus open surgery was compared. OUTCOME MEASURES: The primary outcomes were overall 30-day morbidity and mortality. Secondary outcomes were length of stay, time to resume diet, and need for a permanent stoma. RESULTS: Forty-two patients were identified by using medical records: 24 laparoscopic surgery and 18 open surgery. Baseline demographics, ASA classification, Acute Physiology and Chronic Health Evaluation scores, Hinchey classification, and Charlson Comorbidity Index did not differ between groups. The mean operative time was 36 minutes longer (p = 0.05) and blood loss was 460 mL less (p < 0.001) for laparoscopic surgery. Two patients (8.3%) in the laparoscopic surgery group required conversion to open surgery. There was no mortality. Overall morbidity was lower favoring laparoscopic surgery (16.7% vs 55.6%; p = 0.01). Two patients in the laparoscopic surgery group experienced an anastomotic leak compared with none in the open surgery group. Mean time to resume diet (3 vs 6.5 days; p < 0.01) and length of stay (5 vs 8 days; p = 0.04) were shorter for the laparoscopic surgery group. Rate of permanent stoma at last follow-up (median, 332 days) did not differ significantly between groups. LIMITATIONS: This study is limited by selection bias. CONCLUSIONS: Compared with open surgery, laparoscopic surgery for patients in whom medical treatment for complicated diverticular disease failed is associated with favorable outcomes, including a reduced rate of morbidity and a shorter length of stay. When applied to selected patients, this approach appears to be a safe procedure with a low rate of conversion.

Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option.

BACKGROUND: Anastomotic leaks after low anterior resection for rectal cancer remain a major cause of morbidity and mortality. Few studies have focused on their management, particularly on the technique of transanal drainage. OBJECTIVE: The aim of this study was to assess the short- and long-term outcomes according to the initial management of clinical leaks. DESIGN AND SETTINGS: This study is a retrospective review of a single institution experience. PATIENTS: All patients treated for a symptomatic anastomotic leak after low anterior resection for rectal cancer between January 2000 and March 2011 were included. MAIN OUTCOME MEASURES: The primary outcomes were mortality attributed to the leak, sepsis control, stoma closure rate, and functional results. RESULTS: A total of 37 patients (35 men/2 women) developed a symptomatic leak. Leaks were initially managed by transanal drainage in 16 patients, abdominal reintervention in 12 patients, and medical treatment in 9 patients. The only death attributed to the leak occurred in the abdominal reintervention group. In the transanal drainage group, antibiotics were administered for a median length of 9 days, and the drain was left in place for a median length of 30 days. One patient underwent percutaneous drainage of a collection in addition to transanal drainage, but no patient required abdominal reintervention. Of the treatment modalities applied, transanal drainage was associated with the highest stoma closure rate (93%), after a median postoperative time of 7 months. Complications observed after transanal drainage were anastomotic strictures in 33% and the creation of a permanent stoma due to poor function in 13%. LIMITATIONS: This study was limited by its nonrandomized retrospective design and the presence of selection bias. CONCLUSIONS: : For the management of low anastomotic leaks, transanal drainage allows preservation of the anastomosis and sepsis control with a high rate of ileostomy closure. It is a valuable option in patients with a diverting ileostomy.

Palliative laparoscopic resections for Stage IV colorectal cancer.

PURPOSE: Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares their perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I-III) disease. METHODS: A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student's t-tests as required and P

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures.

INTRODUCTION: The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery. METHODS: The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay. RESULTS: The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days. CONCLUSIONS: The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.