Protective defunctioning stoma in low anterior resection for rectal carcinoma.

BACKGROUND: Anastomotic leak is a serious complication of resection for low rectal carcinoma. METHODS: Data from a prospective multicentre study conducted between January 2000 and December 2001 were analysed to determine the early outcome after low anterior resection in patients with and without a protective stoma. The morbidity and mortality rates associated with ileostomy and colostomy closure were compared. RESULTS: Eight hundred and eighty-one (32.3 per cent) of 2729 patients received a protective stoma after low anterior resection. Overall anastomotic leak rates were similar in patients with or without a stoma (14.5 versus 14.2 per cent respectively). The incidence of leaks that required surgical intervention was significantly lower in those with a protective stoma (3.6 versus 10.1 per cent; P < 0.001), as was the mortality rate (0.9 versus 2.0 per cent; P = 0.037). Logistic regression analysis showed that provision of a protective stoma was the most powerful independent variable for avoiding an anastomotic leak that required surgical correction. Seven hundred and twenty-four of the 881 patients who received a stoma were followed up. The overall postoperative morbidity associated with stoma closure was significantly lower for colostomy than for ileostomy (15.3 versus 22.4 per cent; P = 0.031). CONCLUSION: A protective stoma reduced the rate of anastomotic leakage that required surgical intervention, and mitigated the sequelae of such leakage. Colostomy closure was associated with less morbidity than closure of an ileostomy.

Laparoscopic resection of colon Cancer: consensus of the European Association of Endoscopic Surgery (EAES).

BACKGROUND: The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002. METHODS: A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer. RESULTS: Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery. CONCLUSION: Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

Laparoscopic anterior resection for rectal carcinoma. Results of a registry.

At the present time, laparoscopic anterior resection of the rectum cannot be recommended for routine use. Such operations should be performed for curative intent only within scientifically valid studies. Furthermore, only interventions involving the upper part of the rectum or the rectosigmoidal junction can, on the basis of the morbidity rate, be justified. Procedures done on the low rectum necessitating a total mesorectal excision technically are difficult and, in the present study, are associated with a significant increase in morbidity, in particular anastomotic leakage. Therefore, tumors in the lower two thirds of the rectum that may be eligible for restorative proctectomy should not be treated for curative intent by the laparoscopic approach. General reservations also persist with regard to compliance with the principles of oncologic radicality.

Laparoscopic-assisted colon anastomosis using the Valtrac ring: an animal study.

PURPOSE: For deep colon anastomoses in laparoscopic surgery, the mainstay is the circular stapler. Theoretically, however, such anastomoses can also be constructed with the aid of the Valtrac ring. The aim of the present study was to investigate the feasibility of this approach. METHODS: In this approved animal study nine pigs weighing 15 to 20 kg were operated on under general anesthesia. After intracorporeal preparation, the colon was divided at the level of the entry to the pelvis. To fix the proximal half of the Valtrac ring, the proximal limb of the colon was exteriorized via a minilaparotomy. After replacing this part of the colon--now bearing the Valtrac ring--in the abdominal cavity and reestablishment of pneumoperitoneum, the ring was fixed to the applicator inserted transanally into the abdominal cavity. After placement of the distal half of the ring in the rectal limb and extracorporeal knotting of the pursestring suture previously placed with the aid of the laparoscopic pursestring clamp, the two halves of the Valtrac ring were reliably closed with the help of the applicator. RESULTS: Eight of nine animals survived. One animal died on the fourth postoperative day as a result of an anastomotic insufficiency. At follow-up examination in the fifth postoperative week, none of the surviving eight animals showed any signs of prior anastomotic insufficiency. CONCLUSION: This animal study has shown that using the newly developed applicator system, the Valtrac ring can be just as readily employed as the circular stapler for creation of a colonic anastomosis below the level of the promontorium.