Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials.

OBJECTIVE: To compare long-term oncologic outcomes between laparoscopic and open surgery for rectal cancer and to identify independent predictors of survival. BACKGROUND: Few randomized trials comparing laparoscopic and open surgery for rectal cancer have reported long-term survival data. METHODS: Data from the 3 randomized controlled trials comparing curative laparoscopic (n=136) and open surgery (n=142) for upper, mid, and low rectal cancer conducted at the Prince of Wales Hospital, Hong Kong, between September 1993 and August 2007 were pooled together for this analysis. Survival and disease status were updated to February 2012. Survival was calculated using the Kaplan-Meier method, and independent predictors of survival were determined using the Cox regression analysis. RESULTS: The demographic data of the 2 groups were comparable. The median follow-up time of living patients was 124.5 months in the laparoscopic group and 136.6 months in the open group. At 10 years, there were no significant differences in locoregional recurrence (5.5% vs. 9.3%; P=0.296), cancer-specific survival (82.5% vs. 77.6%; P=0.443), and overall survival (63.0% vs. 61.1%; P=0.505) between the laparoscopic and open groups. There was a trend toward lower recurrence rate at 10 years in the laparoscopic group than in the open group among patients with stage III cancer (P=0.078). The Cox regression analysis showed that stage III cancer, lymphovascular permeation, and blood transfusion, but not the operative approach, were independent predictors of poorer cancer-specific survival. CONCLUSIONS: This pooled analysis with a follow-up of more than 10 years confirms the long-term oncologic safety of laparoscopic surgery for rectal cancer.

Laparoscopic-assisted versus open total mesorectal excision with anal sphincter preservation for mid and low rectal cancer: a prospective, randomized trial.

BACKGROUND: This single-center, prospective, randomized trial was designed to compare the short-term clinical outcome between laparoscopic-assisted versus open total mesorectal excision (TME) with anal sphincter preservation (ASP) in patients with mid and low rectal cancer. Long-term morbidity and survival data also were recorded and compared between the two groups. METHODS: Between August 2001 and August 2007, 80 patients with mid and low rectal cancer were randomized to receive either laparoscopic-assisted (40 patients) or open (40 patients) TME with ASP. The median follow-up time for all patients was 75.7 (range 16.9-115.7) months for the laparoscopic-assisted group and 76.1 (range 4.7-126.6) months for the open group. The primary endpoint of the study was short-term clinical outcome. Secondary endpoints included long-term morbidity rate and survival. Data were analyzed by intention-to-treat principle. RESULTS: The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with less analgesic requirement (P < 0.001), earlier mobilization (P = 0.001), lower short-term morbidity rate (P = 0.043), and a trend towards shorter hospital stay (P = 0.071). The cumulative long-term morbidity rate also was lower in the laparoscopic-assisted group (P = 0.019). The oncologic clearance in terms of macroscopic quality of the TME specimen, circumferential resection margin involvement, and number of lymph nodes removed was similar between both groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 85.9 and 91.3 %, respectively (P = 0.912). The respective probabilities of being disease-free were 83.3 and 74.5 % (P = 0.114). CONCLUSIONS: Laparoscopic-assisted TME with ASP improves postoperative recovery, reduces short-term and long-term morbidity rates, and seemingly does not jeopardize survival compared with open surgery for mid and low rectal cancer ( http://ClinicalTrials.gov Identifier: NCT00485316).

Electroacupuncture reduces duration of postoperative ileus after laparoscopic surgery for colorectal cancer.

BACKGROUND & AIMS: We investigated the efficacy of electroacupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic surgery for colorectal cancer. METHODS: We performed a prospective study of 165 patients undergoing elective laparoscopic surgery for colonic and upper rectal cancer, enrolled from October 2008 to October 2010. Patients were assigned randomly to groups that received electroacupuncture (n = 55) or sham acupuncture (n = 55), once daily from postoperative days 1-4, or no acupuncture (n = 55). The acupoints Zusanli, Sanyinjiao, Hegu, and Zhigou were used. The primary outcome was time to defecation. Secondary outcomes included postoperative analgesic requirement, time to ambulation, and length of hospital stay. RESULTS: Patients who received electroacupuncture had a shorter time to defecation than patients who received no acupuncture (85.9 ± 36.1 vs 122.1 ± 53.5 h; P < .001) and length of hospital stay (6.5 ± 2.2 vs 8.5 ± 4.8 days; P = .007). Patients who received electroacupuncture also had a shorter time to defecation than patients who received sham acupuncture (85.9 ± 36.1 vs 107.5 ± 46.2 h; P = .007). Electroacupuncture was more effective than no or sham acupuncture in reducing postoperative analgesic requirement and time to ambulation. In multiple linear regression analysis, an absence of complications and electroacupuncture were associated with a shorter duration of postoperative ileus and hospital stay after the surgery. CONCLUSIONS: In a clinical trial, electroacupuncture reduced the duration of postoperative ileus, time to ambulation, and postoperative analgesic requirement, compared with no or sham acupuncture, after laparoscopic surgery for colorectal cancer. ClinicalTrials.gov number, NCT00464425.

Laparoscopic colorectal fellowship training programme : a 6-year experience in a university colorectal unit.

BACKGROUND: The aim of this study was to evaluate a structured training programme for laparoscopic colorectal surgery in a university colorectal unit over a 6-year period. METHODS: Data on patients who underwent laparoscopic colectomy between November 2004 and October 2010 were analyzed. Operations were performed either by the consultant colorectal surgeons or colorectal fellows. The effectiveness and safety of our structured training programme were evaluated. RESULTS: During the study period, 813 patients (478 men) with a median age 69 years (range 22-93) underwent laparoscopic colectomy. A total of 370 cases (45.5 %) were performed by four colorectal fellows. Overall, 674 patients (82.9 %) were classified as ASA I or II. The conversion rate was 3.7 %. The conversion rate, intra-operative blood loss, number of lymph nodes retrieved and post-operative recovery were similar between the two groups. When comparing with consultant group, the patients operated by fellows were: (1) significantly older; (2) more were operated on as emergency cases; (3) had pathologically less advanced tumours; (4) less patients with low rectal cancers. There were two surgical mortalities in this series. The morbidities between the two groups were similar. At the end of 3 years of training, the fellows had performed more than 85 cases of laparoscopic colectomies. The level of supervision decreased with increased experience. Finally, experienced fellows were able to supervise more junior colleagues on laparoscopic colectomies. CONCLUSIONS: Our results confirmed a structured training programme for laparoscopic colectomy is safe and effective. Reasonable results were achieved even though a high volume of cases were performed by surgical fellows.

Institution learning curve of laparoscopic colectomy--a multi-dimensional analysis.

BACKGROUND: This study aimed to evaluate the learning curve for laparoscopic colorectal resection of a university colorectal unit, the operative outcome in its developing and established period of laparoscopic colorectal resection is compared. METHODS: We analyzed 1,031 consecutive patients who underwent laparoscopic colorectal resections for colorectal carcinoma performed in a colorectal unit between April 1992 and December 2008. Multi-dimensional analyses of the learning curves of the institution and seven individual surgeons were performed. RESULTS: The operative outcomes of period 2 (2002-2008) was generally better than period 1 (1992-2001), in terms of operative time, number of lymph nodes retrieved, intra-operative blood loss and transfusion. The conversion rate of period 1 was higher than period 2 (19.7% vs. 5.1%, p < 0.001). There were no difference in the rates of intra-operative complications (2% vs. 3.3%, p = 0.32) and major post-operative complications (6% vs. 4.5%, p = 0.28). Analysis of the operative time using moving average method showed that the operative time of period 2 was generally shorter than that of period 1. The operative time transiently increased when there were new trainee surgeons joining the program. The CUSUM analysis of institutional conversion rate showed a steady state being reached at 310 cases. For the rates of intra-operative and major post-operative complications, steady states were both achieved at around 50 cases, and these rates were maintained during the whole study period. CONCLUSIONS: Operative outcome of laparoscopic colorectal resection improved with experience. Continuous training of new trainee would not affect the operative outcomes of an established specialized unit.

Endoscopic submucosal dissection versus local excision for early rectal neoplasms: a comparative study.

BACKGROUND: Transanal local excision (LE) is a well-established treatment option for early rectal neoplasms not amenable to complete colonoscopic removal. Endoscopic submucosal dissection (ESD) has been introduced recently as a novel procedure that enables en bloc resection of large rectal neoplasms. To date, no report comparing the two approaches can be found in the literature. This study aimed to compare the short-term clinical outcomes between ESD and LE for early rectal neoplasms. METHODS: Between 2007 and 2010, 14 patients with early rectal neoplasms deemed not feasible for en bloc endoscopic resection using conventional techniques underwent ESD. They were compared with a matched cohort of 30 patients who had early rectal neoplasms and underwent LE between 2000 and 2009. Short-term clinical outcomes including postprocedure recovery and morbidity were compared between the two groups. RESULTS: The mean lesion size was comparable between the ESD and LE groups (2.9 vs 2.6 cm; P = 0.423), but the mean distance of the lesions from the anal verge was greater in the ESD group (8.6 vs 5.0 cm; P = 0.001). En bloc resection was achieved for 12 patients (85.7%) in the ESD group and for all the patients in the LE group. The ESD group exhibited a trend toward a longer operative time (77.5 vs 50.0 min; P = 0.081) but lower morbidity (7.1 vs 33.3%; P = 0.076). The time to full ambulation was shorter in the ESD group (0 vs 1 day; P = 0.005), but the hospital stay was similar in the two groups (2.5 vs 4.0 days; P = 0.129). CONCLUSION: For the treatment of early rectal neoplasms, ESD offers better short-term clinical outcomes in terms of faster recovery and possibly lower morbidity than LE. Further prospective studies with a larger sample are needed to validate the benefits of rectal ESD.

En bloc urinary bladder resection for locally advanced colorectal cancer: a 17-year experience.

BACKGROUND AND OBJECTIVES: En bloc bladder resection is often required for treating colorectal cancer with suspected urinary bladder invasion. Our aim was to review our institutional experience in en bloc resection of locally advanced colorectal cancer involving the urinary bladder over a period of 17 years. METHODS: The hospital records of 72 patients with locally advanced colorectal cancer who underwent en bloc urinary bladder resection at our institution between July 1987 and December 2004 were retrospectively reviewed. Clinical and oncologic outcomes were evaluated. RESULTS: The mean duration of follow-up was 64.3 months. Genuine tumor invasion into the urinary bladder was confirmed in 34 patients (47%) by histopathology. Forty patients (56%) underwent primary closure of the urinary bladder, while 32 patients (44%) required various kinds of urologic reconstructive procedures. Operative mortality occurred in four patients (6%). The overall postoperative morbidity rate was significantly higher in patients undergoing urologic reconstruction (81% vs. 45%, p = 0.002) when compared to that in patients undergoing primary closure. This was mostly attributable to significantly higher rates of urinary anastomotic leak (21.9% vs. 0%, p = 0.002) and urinary tract infection (50% vs. 18%, p = 0.003) in the urologic reconstruction group. For the 57 patients (79%) who underwent curative resection, the 5-year overall survival rate was 59%, and the local recurrence at 5 years was 15%. Both parameters were not significantly affected by the presence of pathologic bladder invasion or the extent of surgical procedures. CONCLUSIONS: En bloc bladder resection for locally advanced colorectal cancer involving the urinary bladder can produce reasonable long-term local control and patient survival.

Conversion in laparoscopic-assisted colectomy for right colon cancer: risk factors and clinical outcomes.

PURPOSE: Laparoscopic colon resection is technically challenging, and conversion to open surgery is sometimes unavoidable. The impact of conversion may vary among different types of colorectal resection and pathology. Our present study aims at evaluating the risk factors and clinical outcomes of conversion in laparoscopic resection for right colon cancer. METHODS: Between the periods April 1992 to July 2007, 183 consecutive patients undergoing laparoscopic-assisted right colon resection for carcinoma of colon were identified from our database. Data pertaining demographic information, operative details, postoperative course, complications, length of stay, 30-day mortality, and follow-up status were analyzed. RESULTS: The overall conversion rate was 12% (22 patients). Stage IV disease, tumor length >5 cm, and surgery performed in an earlier time period (before year 2002) were independent risk factors for conversion. Although the median operative time was comparable (195 vs 180 min, p = 0.074), more blood loss was recorded among the conversion group (350 vs 20 ml, p < 0.001). Conversion was also associated with higher wound infection rate (27.3% vs 5%, p = 0.002) and 30-day mortality (9.1% vs 0.62%, p = 0.039). After potential curative resection, the 5-year overall survival rate of the conversion and no conversion group was 53.8% and 72.6%, respectively (p = 0.039). CONCLUSIONS: Our results showed that conversion increased the intraoperative blood loss, wound related morbidities, and the 30-day mortality. Moreover, it had negative impact on overall survival.

The learning curve for endorectal ultrasonography in rectal cancer staging.

BACKGROUND: Endorectal ultrasound (ERUS) is an emerging technique for preoperative rectal cancer staging. It is an operator-dependent examination with accuracy closely related to endosonographer experience. In this study, we prospectively analyzed our results of ERUS staging for rectal cancer, aiming to determine its accuracy and to define the learning curve of the procedure. METHODS: Between July 2007 and August 2009, consecutive patients with rectal cancer were recruited for preoperative ERUS staging performed by a single colorectal surgeon. We compared results of ERUS tumor (uT) and nodal (uN) staging with pathological staging of surgical specimens in patients who had surgery without neoadjuvant chemoradiation. To evaluate the learning-curve effect on ERUS, patients were divided into two equal halves for analysis (early group and late group). RESULTS: In the 26-month study period, 50 patients (36 males) with median age of 67 years (range 47-89 years) underwent ERUS staging. The overall accuracy rates of uT and uN staging were 86 and 66%. For uT staging, 10% of tumors were overstaged and 4% were understaged. For uN staging, 22% of patients were overstaged and 12% were understaged. With experience accumulation from early group to late group, accuracy improvement was observed in uN staging (52 vs. 80%, P = 0.037), while the accuracy rate remained consistently high in uT staging (84 vs. 88%, P = 1.0). CONCLUSIONS: ERUS was accurate in preoperative staging of rectal cancer. It was an easy-to-learn procedure for accurate tumor staging, but considerable experience was required to attain accuracy for nodal staging.

In vitro porcine training model for colonic endoscopic submucosal dissection: an inexpensive and safe way to acquire a complex endoscopic technique.

BACKGROUND: Colonic endoscopic submucosal dissection (ESD) has developed in recent years to permit en bloc resection of larger colorectal lesions that cannot be done by standard polypectomy or mucosal resection techniques. Colonic ESD is technically demanding and has a steep learning curve. Adequate training is essential to make ESD a reliable treatment for colorectal neoplasms. We aim to share our early experience with an in vitro porcine training model for colonic ESD. METHOD: Resected porcine distal colon was used to set up a training model for ESD, which was performed as in human using a standard endoscope and dissecting devices. Size of the lesions, operation time, en bloc resection rate, and perforation rate were recorded. RESULTS: Ten consecutive colonic ESD procedures were performed by a single endoscopist. Incomplete resection and perforation were encountered during the first two procedures. No perforation occurred in subsequent procedures and the operation time per task also decreased gradually. The setup cost for this model was only around US $30. CONCLUSIONS: The in vitro porcine model is easy and inexpensive to set up. Our initial experience showed that the model could simulate colonic ESD in human and technical proficiency improved by repetition. This simple setup may be a promising training model for endoscopists working in areas with a low incidence of early gastric cancer.

Emergency laparoscopic-assisted versus open right hemicolectomy for complicated cecal diverticulitis: a comparative study.

BACKGROUND: Emergency open colectomy is generally agreed, by most surgeons, to be the treatment of choice for complicated cecal diverticulitis. However, the literature on the use of laparoscopy in treating this surgical emergency is scanty. This study aimed to evaluate the feasibility and safety of emergency laparoscopic-assisted right hemicolectomy for complicated cecal diverticulitis and to compare its operative and short-term clinical outcomes with the open approach. PATIENTS AND METHODS: Between September 2001 and June 2006, 18 consecutive patients with an intraoperative diagnosis of complicated cecal diverticulitis underwent emergency right hemicolectomy at our institution, 6 with the laparoscopic-assisted approach and 12 with the open approach. Clinical data were retrospectively collected and compared between the two groups. RESULTS: The demographic data of the two groups were comparable. The operative time was similar between the two groups, but the laparoscopic-assisted group had significantly less blood loss (35 vs. 100 mL; P = 0.041). Although the time to first bowel motion was significantly shorter in the laparoscopic-assisted group (3.5 vs. 5 days; P = 0.041), the time to full ambulation and the duration of hospital stay were not different between the two groups. More patients in the open group developed postoperative complications (50 vs. 33.3%), but the difference was not statistically significant. CONCLUSIONS: With the availability of experienced laparoscopic surgeons, emergency laparoscopic-assisted right hemicolectomy can be safely performed in patients with complicated cecal diverticulitis. Compared with the open approach, the laparoscopic-assisted approach is associated with less blood loss and earlier return of bowel function.

Long-term morbidity and oncologic outcomes of laparoscopic-assisted anterior resection for upper rectal cancer: ten-year results of a prospective, randomized trial.

PURPOSE: We have previously reported the five-year results of a randomized trial comparing laparoscopic and open resection for cancer of the upper rectum and rectosigmoid junction. The aim of this follow-up study is to report on the long-term morbidity and ten-year oncologic outcomes among the subgroup of patients with upper rectal cancer. METHODS: From September 1993 to October 2002, 153 patients with upper rectal cancer were randomly assigned to receive either laparoscopic-assisted (n = 76) or open (n = 77) anterior resection. Patients were last followed up in December 2007. Long-term morbidity, survival, and disease-free interval were prospectively recorded. Data were analyzed by intention-to-treat principle. RESULTS: The demographic data of the two groups were comparable. More patients in the open group developed adhesion-related bowel obstruction requiring hospitalization (P = 0.001) and intervention. The overall long-term morbidity rate was also significantly higher in the open group (P = 0.012). After curative resection, the probabilities of cancer-specific survival at ten years of the laparoscopic-assisted and open groups were 83.5 percent and 78.0 percent, respectively (P = 0.595), and their probabilities of being disease-free at ten years were 82.9 percent and 80.4 percent, respectively (P = 0.698). CONCLUSION: Laparoscopic-assisted anterior resection for upper rectal cancer is associated with fewer long-term complications and similar ten-year oncologic outcomes when compared with open surgery.

The learning curve for laparoscopic colectomy: experience of a surgical fellow in an university colorectal unit.

BACKGROUND: This study aimed to evaluate the learning curve for laparoscopic colectomy of a surgical fellow in an university colorectal unit using a structured training protocol. METHODS: This study analyzed the data from 100 consecutive patients who had laparoscopic colectomy performed by a surgical fellow between 11/2004 and 12/2007. The structured training protocol required the fellow to assist more than 40 laparoscopic colectomies before embarking on his first case. Rectosigmoidectomy was prioritized during the initial experience. Operative times were analyzed to represent the learning curve. Other outcome data including conversion and operative outcome were also evaluated. RESULTS: The following procedures were performed: 49 rectosigmoidectomies, 38 right colon resections, and 13 other resections. Median operative time was 150 min, and conversion rate was 1%. Overall postoperative morbidity rate was 28% (major morbidity 3%). Three patients required early reoperation. There was no operative death. Median hospital stay was 8 days. Operative times reached their lowest point at period of cases 45-50, and remained relatively stable afterwards. Comparing the first 50 and second 50 cases, the only difference observed was more frequent presence of a supervisor in the theater in the first 50 cases (74% versus 52%, p = 0.02), while the other parameters including types of procedures, postoperative recovery, hospital stay, and morbidity rate were not different. CONCLUSIONS: Our results indicated that laparoscopic colectomy training can be safely performed under a structured protocol. The surgeon can perform laparoscopic colectomies more independently after 50 cases, without jeopardizing the clinical outcome.

Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial.

BACKGROUND: Laparoscopic resection of colonic cancer has been shown to improve postoperative recovery without jeopardizing tumor clearance and survival, but information on low rectal cancer is scarce. The aim of this randomized trial was to compare postoperative recovery between laparoscopic-assisted versus open abdominoperineal resection (APR) in patients with low rectal cancer. Recurrence and survival data were also recorded and compared between the two groups. METHODS: Between September 1994 and February 2005, 99 patients with low rectal cancer were randomized to receive either laparoscopic-assisted (51 patients) or conventional open (48 patients) APR. The median follow-up time of living patients was about 90 months for both groups. The primary and secondary endpoints of the study were postoperative recovery and survival, respectively. Data were analyzed by intention-to-treat principle. RESULTS: The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with earlier return of bowel function (P < .001) and mobilization (P = .005), and less analgesic requirement (P = .007). This was at the expense of longer operative time and higher direct cost. There were no differences in morbidity and operative mortality rates between the two groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 75.2% and 76.5% respectively (P = .20). The respective probabilities of being disease-free were 78.1% and 73.6% (P = .55). CONCLUSIONS: Laparoscopic-assisted APR improves postoperative recovery and seemingly does not jeopardize survival when compared with open surgery for low rectal cancer. A larger sample size is needed to fully assess oncological outcomes.

Emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma: a comparative study of short-term clinical outcomes.

BACKGROUND: The aim of the present study was to compare the clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma. METHODS: Between July 2003 and July 2006, 43 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 14 with the laparoscopic-assisted approach and 29 with the open approach. Clinical data were retrospectively recorded and compared between the two groups. RESULTS: There were no significant differences between the two groups with respect to age, gender, co-morbidities, duration of obstructing symptoms, tumor length, and tumor staging. The laparoscopic-assisted group had longer operative time than the open group (187.5 min versus 145 min; p=0.034) but less blood loss (20 ml versus 100 ml; p=0.020). The median time to full ambulation was significantly shorter in the laparoscopic-assisted group (4 days versus 6 days; p=0.016), but the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (55.2% versus 28.6%), but the difference was not statistically significant. CONCLUSIONS: Emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. In comparison with the open approach, the laparoscopic-assisted procedure is associated with less blood loss, earlier ambulation, and possibly lower morbidity rate.

Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms.

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.

Rectal stump lavage: simple procedure resulting in life-threatening complication.

In colorectal resections, rectal stump lavage is commonly performed prior to primary anastomosis for reducing bacterial counts and minimizing the risk of anastomotic recurrence. Being a potent bactericidal and cytotoxic disinfectant, chlorhexidine is frequently chosen as the irrigation solution of choice for such purposes. Despite its widespread use, the potential for developing chlorhexidine allergy is still a major concern due to the ever-rising number of literature reports of hypersensitivity reactions to chlorhexidine in surgical patients. This report illustrates the first reported case of life-threatening chlorhexidine anaphylaxis after its use in rectal stump lavage for colorectal resection. This report serves as a reminder of the potential danger of this "hidden allergen" in clinical practice.

Critical appraisal on the role and outcome of emergency colectomy for uncomplicated right-sided colonic diverticulitis.

BACKGROUND: Emergency colectomy is well accepted for treating complicated right-sided colonic diverticulitis. However, the role of colectomy for uncomplicated diverticulitis is not well defined. The aim of this study was to evaluate the short-term and long-term surgical outcome of uncomplicated right-sided diverticulitis in our locality. PATIENTS AND METHODS: Retrospective chart review of patients operated for right-sided diverticulitis over a 20-year period was conducted. Recurrent attacks of right-sided diverticulitis, re-operation rate and re-hospitalisation rate were the long-term parameters of interest. An updated telephone interview was carried out for all surviving patients. RESULTS: Seventy-four patients (35 males and 39 females), median age 35.5 (range 16-70) years, were operated for uncomplicated diverticulitis. Thirty patients underwent colectomy, whereas the others underwent appendectomy with diverticulectomy (n = 8) or appendectomy alone (n = 36). All short-term parameters were less favourable for the colectomy group, including higher complication rate, slower return of gastrointestinal function, higher requirement of parenteral analgesic and longer hospital stay. Without colectomy, only 2 patients developed recurrent diverticulitis necessitating hospitalisation, both of whom resolved on conservative treatment. On the other hand, 1 patient required re-operation after colectomy because of intestinal obstruction. The overall re-hospitalisation rate was comparable between the colectomy and the non-colectomy group (16.7% vs. 13.6%). CONCLUSIONS: Emergency colectomy can eradicate suspicious lesions and eliminate risk of recurrent diverticulitis but at the expense of higher morbidity rates. As the natural course of uncomplicated right-sided colonic diverticulitis is usually benign, conservative treatment with minimal surgery may be a better therapeutic option.

Emergency laparoscopically assisted right hemicolectomy for obstructing right-sided colon carcinoma.

BACKGROUND: We report our preliminary experience in urgent laparoscopically assisted right hemicolectomy for obstructing right-sided colon carcinoma. MATERIALS AND METHODS: From January to April 2005, seven consecutive patients with obstructing right-sided colon carcinoma underwent emergency laparoscopically assisted right or extended right hemicolectomy. Patient demographic data, operative details, and short-term clinical outcomes were prospectively collected and analyzed. RESULTS: The median duration of obstructing symptoms prior to admission was 3 days (range, 1-6 days). Two patients underwent palliative resection and five patients underwent curative resection. The median operative time was 180 minutes (range, 125-350 minutes). There were no conversions to the open procedure. Median blood loss was 30 mL (range, negligible-300 mL). The median times to resuming diet, first bowel motion, and full ambulation were 4 days (range, 3-10 days), 5 days (range, 3-7 days), and 4 days (range, 4-5 days), respectively. The median duration of hospital stay was 7 days (range, 6-19 days). One patient with ischemic heart disease developed acute coronary syndrome postoperatively and died on postoperative day 19. The remaining patients had no complications. The median tumor length was 3.5 cm (range, 2-5 cm) and the median number of lymph nodes removed was 17 (range, 16-36). CONCLUSION: Emergency laparoscopically assisted right hemicolectomy for obstructing right-sided colon carcinoma is feasible and safe, with favorable short-term clinical outcomes and an acceptable number of lymph nodes removed.

Simultaneous laparoscopic resection of rectal cancer and liver metastasis.

Simultaneous resection of colorectal tumor and liver metastasis has been advocated because of the benefits of avoiding a second operation, reduced morbidity, shorter treatment time, and similar outcomes. We report a case of simultaneous laparoscopic resection. The operative time was 350 minutes and the estimated blood loss was 500 mL. The patient required parenteral analgesia for less than 48 hours. Flatus was passed on postoperative day 3, and a solid diet was resumed on postoperative day 5. He was fully mobile on postoperative day 4 and was discharged 3 days later. With the advance of laparoscopic technology and technique, simultaneous resection becomes an attractive option.