Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery.

BACKGROUND AND AIMS: High ligation of the inferior mesenteric artery may jeopardize blood supply to the proximal bowel. We undertook this study to review the clinical features and outcomes of patients who developed proximal bowel necrosis after high ligation of the inferior mesenteric artery, and to assess the incidence and the risk factors for this complication. MATERIALS AND METHODS: A retrospective analysis of patients undergoing high or low ligation for sigmoid colon and rectal cancer with a primary anastomosis between April 2004 and March 2009 was performed. Patient and tumor characteristics and the incidence of bowel necrosis were reviewed. RESULTS: Four hundred and nine patients were included to the analysis. Six out of 302 patients (2.0%) with high ligation developed proximal bowel necrosis, while the remaining 107 patients with low ligation did not suffer from this complication. All patients who developed proximal bowel necrosis underwent secondary surgery with resection of necrotic bowel. The pathological examination of the resected specimen revealed mucosal to transmural ischemic necrosis without the evidence of vascular thrombosis or embolic occlusion. Univariate analysis revealed that advanced age, cerebrovascular disease, and hypertension were significantly associated with proximal bowel necrosis. Multivariate analysis demonstrated that cerebrovascular disease was an independent predictor of this complication. Of these six patients, two died from associated complications. CONCLUSIONS: Proximal bowel necrosis after high ligation is potentially fatal, and this report provides a warning in clinical settings where high ligation is indicated. Further studies are warranted to evaluate its distinct relationship with high ligation and to clarify whether low ligation would be a safeguard.

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision.

BACKGROUND: Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program. METHODS: A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously. RESULTS: Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery. CONCLUSIONS: Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.

Distribution of the first metastatic lymph node in colon cancer and its clinical significance.

INTRODUCTION: The pattern of distribution of lymph node metastasis in resected specimens of colon cancer has been rarely reported in the English literature. The aim of this study was to determine the location of the first metastatic lymph node, giving insight into the drainage pattern of colon cancer lymphatics. METHOD: All lymph nodes in the mesentery of the resected specimen were carefully harvested and their precise locations documented. Patients with a single metastatic node in the resected specimen were included in the study. RESULTS: Ninety-three patients with only one metastatic lymph node found on histology were studied. The mean number of lymph nodes per specimen was 22.3 (range: 8-72). The patients' first metastatic node was not directly below the tumour in 48% of cases. The first metastatic node was found in the region either along the feeding vessels (skipping the pericolic nodes) or in the pericolic area outside 5 cm on either side of the tumour edge in 18% of cases. No factors were found to be predictive for lymph node metastasis occurring elsewhere other than in the pericolic region just below the tumour. CONCLUSION: Although there has been recent resurgence of interest in using sentinel node biopsy to limit surgical dissection to facilitate minimally access and natural orifice surgery, the present study is a warning that this may compromise oncological clearance. Radical surgery should remain standard practice for colorectal cancer.

Sushi-roll wrap of Seprafilm for ileostomy limbs facilitates ileostomy closure.

BACKGROUND: Sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) reduced postoperative intraabdominal adhesion. In this study, we examined whether Seprafilm reduces operative difficulties in ileostomy closure. PATIENTS AND METHODS: During the creation of the ileostomy, Seprafilm was cut in half and used to wrap both the ileum and mesentery. Patients who underwent ileostomy closure before February 2008 (without Seprafilm, Group T, n = 18) and after March (with Seprafilm, Group S, n = 18) were enrolled in this study. All operations were performed by surgical residents. Operative time and perioperative complications were analyzed. RESULTS: The mean operative time of Group S (106.88 min) was significantly less than that of Group T (120.6 min). The amount of intraoperative bleeding in Groups S and T was not significantly different and there were no major complications. CONCLUSION: Seprafilm applied to the two limbs of the ileostomy and mesentery facilitate ileostomy closure done by non-expert surgeons.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity.

INTRODUCTION: Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer. METHODS: A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates. RESULTS: The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity. CONCLUSION: Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Prophylactic ureteric catheters in laparoscopic colorectal surgery.

BACKGROUND: The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure. METHODS: Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed. RESULTS: Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group. CONCLUSION: Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.