Impact of obesity on laparoscopic-assisted left colectomy in different stages of the learning curve.

PURPOSE: This study is aimed at verifying if the surgeon's experience has an impact on the risk of conversion to open surgery of laparoscopic left colectomy performed in obese patients. METHODS: A multiple logistic regression analysis was performed of 181 laparoscopic left hemicolectomies completed between April 2001 and June 2006. The results were analysed statistically in relation to the learning curve, by comparing factors that could have had an impact on the risk of conversion in the first 91 cases and in the last 90 cases. RESULTS: The overall conversion rate was 11%. Only weight level was found to be predictive of conversion to open surgery. No death was observed. Sixteen patients presented postoperative complications (8.8%), with no significant differences between obese and nonobese patients (P=0.95). The conversion rate was higher in the group of the first 91 cases: 15.6% versus 6.6% (P=0.05). Average body mass index of converted patients resulted as being higher than that of nonconverted ones (29.97+/-3.76 vs. 25.48+/-3.72; P<0.001) during the first period of the learning curve, but the difference was not observed during the second period (P=0.87). On multiple logistic regression analysis, obesity was found to be predictive of conversion only during the first period. CONCLUSIONS: The data indicate that the laparoscopic colorectal surgery is feasible and effective in obese patients both when the surgeon is expert in laparoscopic colorectal resection and at the initial phase of the experience. At the initial phase of the experience obesity constitutes a higher risk of conversion to open surgery.

Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy.

BACKGROUND: Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation. METHODS: Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured. RESULTS: Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months. CONCLUSIONS: The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.

Predicting conversion to open surgery in laparoscopic left hemicolectomy.

PURPOSE: The objective of this study was to quantify the risk of conversion to open surgery of laparoscopic left hemicolectomy at an early stage of the learning curve. METHODS: A multiple logistic regression analysis of 100 laparoscopic left hemicolectomies completed between April 2001 and May 2004 was performed. RESULTS: The overall conversion rate was 12%. At univariate analysis, 2 factors were found to be predictive of conversion to open surgery: malignancy (17.2% vs. 5%; P=0.046), and weight level (<60 kg=6.1%; 60 to 90 kg=11.3%; >90 kg=28.6%; P=0.049). At multiple logistic regression, the risk of conversion rose only for patients weighing more than 90 kg. CONCLUSIONS: On the basis of the results of this study, the surgeon will be able to quantify the risk of conversion to laparotomy with some precision in order to obtain the informed consent of the first 100 patients to whom laparoscopic left hemicolectomy is proposed.

Prospective comparison of laparoscopic left hemicolectomy for colon cancer with laparoscopic left hemicolectomy for benign colorectal disease.

BACKGROUND: Short-term outcome and anorectal function results after laparoscopic hemicolectomy for colon cancer were compared with results after laparoscopic hemicolectomy for benign diseases. METHODS: A total of 108 patients who underwent laparoscopic left colectomy (60 for colon cancer, 48 for diverticulitis or polyposis) were enrolled in the study. Left hemicolectomy in patients affected by cancer was performed by high ligation of the inferior mesenteric artery. A questionnaire concerning anorectal function was mailed to patients 6 months after surgery. RESULTS: Complications were more frequent in the cancer group than in the benign disease group: overall morbidity rate (29.6% versus 8.7%; P = 0.009), diarrhea during the first 6 postoperative months (58.7% versus 34.1%; P = 0.022), and anorectal function problems (fecal incontinence and/or the inability to discriminate between gas and stool, and/or urgency, and/or tenesmus) (65.2% versus 31.7%; P = 0.002). DISCUSSION: The level of ligation of the lower mesenteric artery and damage at the lower mesenteric ganglion could explain the poorer anorectal function outcome in the colon cancer group.

Anorectal function problems after left hemicolectomy.

BACKGROUND: The aim of this study was to evaluate the subjective anorectal function in patients with left hemicolectomy and to clarify the clinical factors influencing postoperative anorectal function problems. MATERIALS AND METHODS: One hundred and twenty one patients who underwent left hemicolectomy from April 2002 to December 2003 were enrolled in this study and sent questionnaires concerning anorectal function. Left hemicolectomy in patients with cancer was performed by high ligation of the inferior mesenteric artery; in patients with diverticulitis or polyposis, the inferior mesenteric artery was cut just below the branch of the left colonic artery. One hundred patients replied to the questionnaire: 52 men and 48 women, aged 37 to 85, with a mean age of 66.6 years. Differences were analyzed for statistical significance by the Chi square test and by logistic regression. RESULTS: Anorectal function problems was present in 33% of patients: female gender (P = 0.02), laparoscopic surgery (P = 0.04), and postoperative diarrhea (P = 0.04) had significant independent effects on anorectal function problems. Transient early fecal incontinence was observed in 16% of patients and laparoscopic surgery had significant independent effects on this problem (P = 0.04). Inability to discriminate between gas and stool, tenesmus, or urgency were present in 21%, 18%, and 17% of cases, respectively, and were independently associated respectively with laparoscopic surgery (P = 0.005) and postoperative diarrhea (P = 0.019) (P = 0.015). CONCLUSION: In our study the following two issues were clarified: anorectal function problems are frequent after left hemicolectomy, and the laparoscopic technique is linked to poor postoperative anorectal function. The technical methods of high ligation of the inferior mesenteric artery could explain this result.

Number of lymph nodes examined and prognosis of TNM stage II colorectal cancer.

The diagnosis of a lymph node-negative colorectal carcinoma should imply a good prognosis; however, the outcomes for TNM stage II patients remain variable. Few studies have examined the relationship of the number of lymph nodes examined to the prognosis of this stage. The aim of this study was to determine whether the number of lymph nodes examined has an effect on prognosis of a relatively large sample of patients undergoing curative surgery for stage II colorectal cancer at a single institution. Data on patients who underwent surgery for colorectal cancer between January 1980 and April 2000 were prospectively collected in a database. Patients with TNM stage II or stage III tumours who were treated with curative intent were removed. Patients over 80 years of age were excluded from the survival analysis. Survival comparisons were made using Kaplan-Meier curves and the log-rank test. Multivariate analysis was performed using a Cox regression model. A total of 625 cases of TNM stage II cases and, for comparison purposes, 415 stage III cases, were analysed. Lymph node retrieval in stage II cases was affected by the patient's age (P=0.04) and gender (P=0.02), tumour grade (P<0.0001), tumour site (P<0.0001), and necessity to carry out extended resection (P<0.0001). In stage III cases, lymph node retrieval was affected by patient age (P<0.0001), tumour grade (P=0.02), and tumour site (P=0.002). Decreased lymph node detection was associated with increasing hazard ratios among the 480 TNM stage II patients under 80 years of age, but not among the 345 patients with TNM stage III tumours. Five year survival rate for patients with stage III tumours with only 1-3 positive lymph nodes (52.6%) was similar to that of patients with stage II tumour who had nine or fewer lymph nodes examined (51.3%). These results demonstrate that the prognosis of TNM stage II colorectal cancer is dependent on the number of lymph nodes examined. Patients with few nodes examined have a poorer prognosis. It is possible that a smaller number of lymph nodes examined reflects a diminished immune response. It can be presumed that those patients with stage II tumour with only a few nodes examined should be offered postoperative chemotherapy on a routine basis.