RESUMO
BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
Assuntos
Colo/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos Eletivos , Assistência Perioperatória , Guias de Prática Clínica como Assunto , Reto/cirurgia , Protocolos Clínicos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Humanos , Assistência Perioperatória/métodos , Recuperação de Função FisiológicaRESUMO
BACKGROUND: Colovesical fistula secondary to diverticular disease is increasing in incidence. Presentation and severity may differ, but a common management strategy may be applied. The aim of this study is to evaluate the characteristics and perioperative management of patients with colovesical fistulae and determine optimal management. METHODS: From 2003 to 2012, all charts of surgical patients with diverticular colovesical fistulae at two different institutions were reviewed. Patient and presentation characteristics and perioperative management and outcomes were recorded. Patient groups with early and late catheter removal (< 8 and ≥ 8 days) were compared with significance level set at p < 0.05. RESULTS: Seventy-eight patient charts were reviewed. The mean duration of symptoms was 7.5 months. Laparoscopic assisted surgery was carried out in 35% of patients. Complex bladder repair was performed in 27%. Mean length of stay was 8 days. Mean urinary catheter duration was 13 days. Seventy percent of patients underwent postoperative cystogram, with 4% positive for extravasation. Patients with early catheter removal were significantly older, more likely to have received intraoperative methylene blue instillation, and less likely to have had a complex bladder repair (p < 0.05). Complication rate, length of stay, postoperative cystography, and stent use were similar for both catheter removal groups. CONCLUSIONS: Intraoperative methylene blue bladder instillation should be utilized to limit unnecessary bladder repairs. In the setting of negative methylene blue extravasation, surgeons may confidently remove urinary catheters in 7 days or less, in some cases as early as 48 h. In complex bladder repairs, cystogram is still an important adjunct, with those patients with negative studies benefiting from catheter removal at 7 days or less.
Assuntos
Doenças do Colo/cirurgia , Doenças Diverticulares/complicações , Fístula Intestinal/cirurgia , Laparoscopia/métodos , Fístula da Bexiga Urinária/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/etiologia , Inibidores Enzimáticos/administração & dosagem , Feminino , Humanos , Fístula Intestinal/etiologia , Cuidados Intraoperatórios/métodos , Tempo de Internação , Masculino , Azul de Metileno/administração & dosagem , Pessoa de Meia-Idade , Resultado do Tratamento , Bexiga Urinária/cirurgia , Cateterismo Urinário/métodosRESUMO
AIM: Surgery aims to prevent cancer-related morbidity for patients with ulcerative colitis (UC) associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterize the likelihood of the development of colorectal cancer (CRC) of patients with UC-associated dysplasia who chose to defer surgery. METHOD: A retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated. RESULTS: In all, 175 patients underwent surgery at a median of 4.9 (interquartile range 2.5-8.9) months after a diagnosis of dysplasia. Their median age was 52 (interquartile range 43-59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC [0/23; 17.7 (8.1-29.6) months]. Thirty-six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low-grade dysplasia [24.2 (11.0-30.4) months]. Low-grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions [7.4 (5.2-33.3) months]. Eighteen patients progressed from indeterminate to high-grade dysplasia [19.1 (9.2-133.9) months]. Seventeen patients progressed from low to high-grade dysplasia [11.0 (5.8-30.1) months]. None of the patients with high-grade dysplasia (0/35) progressed to CRC [4.5 (1.7-9.9) months]. CONCLUSION: Dysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to 5 years. These findings may help inform the decision-making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC-associated dysplasia.
Assuntos
Colite Ulcerativa/complicações , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/etiologia , Lesões Pré-Cancerosas/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Adulto , Biópsia , Carcinoma/epidemiologia , Carcinoma/etiologia , Colite Ulcerativa/cirurgia , Colo/patologia , Colo/cirurgia , Colonoscopia/efeitos adversos , Neoplasias Colorretais/epidemiologia , Progressão da Doença , Feminino , Humanos , Incidência , Funções Verossimilhança , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Lesões Pré-Cancerosas/complicações , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
Interstitial cells of Cajal (ICC) are specialized mesenchyme-derived cells that regulate contractility and excitability of many smooth muscles with loss of ICC seen in a variety of gut motility disorders. Maintenance of ICC numbers is tightly regulated, with several factors known to regulate proliferation. In contrast, the fate of ICC is not established. The aim of this study was to investigate whether apoptosis plays a role in the regulation of ICC numbers in the normal colon. ICC were identified by immunolabelling for the c-Kit receptor tyrosine kinase and by electron microscopy. Apoptosis was detected in colon tissue by immunolabelling for activated caspase-3, terminal dUTP nucleotide end labelling and by ultrastructural changes in the cells. Apoptotic ICC were identified and counted in double-labelled tissue sections. They were identified in all layers of the colonic muscle. In the muscularis propria 1.5 +/- 0.2% of ICC were positive for activated caspase-3 and in the circular muscle layer 2.1 +/- 0.9% of ICC were positive for TUNEL. Apoptotic ICC were identified by electron microscopy. Apoptotic cell death is a continuing process in ICC. The level of apoptosis in ICC in healthy colon indicates that these cells must be continually regenerated to maintain intact networks.
Assuntos
Apoptose/fisiologia , Colo/citologia , Colo/patologia , Adulto , Idoso , Feminino , Humanos , Imuno-Histoquímica , Marcação In Situ das Extremidades Cortadas , Masculino , Microscopia Eletrônica de Transmissão , Pessoa de Meia-IdadeRESUMO
PURPOSE: Management of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications. METHODS: The outcome of patients who underwent treatment for anal fistula with the Surgisis anal plug was retrospectively reviewed. RESULTS: Twenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans-sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow-up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully. CONCLUSIONS: Contrary to other published series, the use of the Surgisis anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.
Assuntos
Implantes Absorvíveis , Fístula Retal/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Retalhos CirúrgicosRESUMO
BACKGROUND: Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication. METHODS: All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn's (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient. RESULTS: Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion. CONCLUSIONS: SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement.
Assuntos
Doenças do Colo/cirurgia , Obstrução Intestinal/cirurgia , Doenças Retais/cirurgia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças do Colo/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Doenças Retais/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The initial enthusiastic application of laparoscopic techniques to colorectal surgical procedures was tempered in the early 1990s by reports of tumor implants in the laparoscopic incisions. Substantial evidence has accumulated, including evidence from randomized controlled trials, to support that laparoscopic resection results in oncologic outcomes similar to open resection, when performed by well-trained, experienced surgeons. This review was developed in conjunction with guidelines published by the Society of American Gastrointestinal and Endoscopic Surgeons. Data from the surgical literature concerning laparoscopic resection of curable colorectal cancer was evaluated regarding diagnostic evaluation, preoperative preparation, operative techniques, prevention of tumor implants, and training and experience. Recommendations are accompanied by an assessment of the level of supporting evidence available at the time of the development of the guidelines.
Assuntos
Colectomia/métodos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Laparoscopia/métodos , Colonoscopia/efeitos adversos , Colonoscopia/métodos , Neoplasias Colorretais/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/prevenção & controle , Proctoscopia/efeitos adversos , Proctoscopia/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de RiscoRESUMO
Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-12% and fecal continence has been documented to improve in 3-75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparoscopic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at http://dx.doi.org/10.1007/s00464-006-0136-y.
Assuntos
Incontinência Fecal/cirurgia , Laparoscopia/métodos , Prolapso Retal/cirurgia , Idoso , Cirurgia Colorretal/métodos , Endossonografia , Incontinência Fecal/diagnóstico , Incontinência Fecal/etiologia , Feminino , Seguimentos , Humanos , Manometria , Prolapso Retal/complicações , Medição de Risco , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. METHODS: Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for > or =85% of patients. RESULTS: Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was > or =85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. CONCLUSIONS: EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.
Assuntos
Doença de Crohn/diagnóstico , Fístula Retal/diagnóstico , Adolescente , Adulto , Idoso , Anestesia , Doença de Crohn/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Pelve/patologia , Estudos Prospectivos , Fístula Retal/cirurgia , Reto/diagnóstico por imagem , UltrassonografiaAssuntos
Neoplasias Colorretais/cirurgia , Laparoscopia/métodos , Competência Clínica/normas , Colectomia/efeitos adversos , Colectomia/métodos , Colectomia/normas , Seguimentos , Cirurgia Geral/educação , Cirurgia Geral/normas , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/normas , Inoculação de Neoplasia , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Resultado do TratamentoRESUMO
Colonic diverticular disease is common but surprisingly poorly understood. Recent advances in the field continue to focus on the introduction of new technology. Diagnosis and assessment of the severity of acute diverticulitis is improved with CT scanning. A specialized bleeding team employing advanced endoscopic techniques can control diverticular bleeding so that emergency surgical resection may be avoided. Selected patients undergoing laparoscopic sigmoid resection may benefit from this approach. The vast majority of reports are from retrospective studies and include few randomized, controlled trials.
Assuntos
Colectomia/métodos , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/terapia , Divertículo do Colo/diagnóstico , Divertículo do Colo/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Laparoscopia/métodos , Colonoscopia/métodos , Colostomia/métodos , Doença Diverticular do Colo/epidemiologia , Divertículo do Colo/complicações , Divertículo do Colo/epidemiologia , Hemorragia Gastrointestinal/etiologia , HumanosRESUMO
Clostridium difficile is a spore-forming toxigenic bacterium that causes diarrhea and colitis, typically after the use of broad-spectrum antibiotics. The clinical presentation ranges from self-limited diarrhea to fulminant colitis and toxic megacolon. The incidence of this disease is increasing, resulting in major medical and economic consequences. Although most cases respond quickly to medical treatment, C difficile colitis may be serious, especially if diagnosis and treatment are delayed. Recurrent disease represents a particularly challenging problem. Prevention is best accomplished by limiting the use of broad-spectrum antibiotics and following good hygienic techniques and universal precautions to limit the transmission of bacteria. A high index of suspicion results in early diagnosis and treatment and potentially reduces the incidence of complications.
Assuntos
Antibacterianos/efeitos adversos , Clostridioides difficile , Infecções por Clostridium/etiologia , Diarreia/etiologia , Enterocolite Pseudomembranosa/etiologia , Adulto , Antibacterianos/uso terapêutico , Portador Sadio/diagnóstico , Portador Sadio/epidemiologia , Portador Sadio/microbiologia , Portador Sadio/terapia , Causalidade , Criança , Infecções por Clostridium/diagnóstico , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/terapia , Diagnóstico Diferencial , Diarreia/diagnóstico , Diarreia/epidemiologia , Diarreia/terapia , Enterocolite Pseudomembranosa/diagnóstico , Enterocolite Pseudomembranosa/epidemiologia , Enterocolite Pseudomembranosa/terapia , Humanos , Incidência , Lactente , Controle de Infecções/métodos , Prevenção Primária/métodos , Recidiva , Precauções UniversaisRESUMO
PURPOSE: The purpose of this study was to develop a surgical training program and to test the accuracy of laparoscopic ultrasound in detecting injected lesions in pig livers. METHODS: Pig livers were divided into eight segments and injected with Surgilube "malignant" and silicone "benign" lesions. All were examined by laparoscopic ultrasound followed by liver explantation to confirm results. First, a pilot study was conducted on six swine by injecting Surgilube lesions and performing laparoscopic ultrasound through 3 different ports (left upper quadrant (I), umbilicus (II), and right lower quadrant (III)) to determine per-segment accuracy and to optimize port placement. Second, blinded injection of Surgilube and silicone implants was done on 18 pigs with laparoscopic ultrasound conducted through the two most accurate ports from the pilot study. This model was then tested during a resident training workshop. RESULTS: In the pilot study, per-lesion and per-segment sensitivity was 96 percent, with no difference among the three ports used. Ports I and II were chosen for the blinded study for their convenience in performing laparoscopic colectomy. In the blinded study, per-segment sensitivity, specificity, and accuracy were 97 percent, 94 percent, and 96 percent and 99 percent, 94 percent, and 97 percent for ports I and II, respectively. At the conclusion of a pilot workshop, trainee per-segment sensitivity, specificity, and accuracy were 60 percent, 80 percent, and 70 percent, respectively. The major difficulty was differentiating benign from malignant lesions. CONCLUSIONS: A useful liver laparoscopic ultrasound training model for surgeons was developed with good preliminary results. It is anticipated that further training will enhance laparoscopic ultrasound accuracy rates before application of this modality in humans.
Assuntos
Colectomia/métodos , Cirurgia Geral/educação , Laparoscopia/métodos , Fígado/diagnóstico por imagem , Ultrassonografia/métodos , Animais , Competência Profissional , SuínosRESUMO
BACKGROUND: Laparoscopic colorectal procedures are considered to be technically challenging, and there is a lack of consensus regarding the magnitude of their benefits. The laparoscopic approach is generally held to be more expensive. Using a model of a single procedure performed for a single indication (ileocolic resection for Crohn's disease [CD]), we set out to demonstrate the feasibility of this procedure by determining the conversion rate, documenting the patient benefits, and performing a formal cost analysis. METHODS: Consecutive cases of laparoscopic ileocolic resection for CD were identified (LAP). Case-match methodology identified a series of open laparotomy controls (OPEN) that were matched for five potential confounding criteria: age, gender, diagnosis, type of resection, and date of operation. Pre-, intra-, and postoperative details were gathered. Medical resource utilization was tracked using a standardized database, and all costs were reported in 1999 dollars. RESULTS: The conversion rate was 5.9%. Resolution of ileus occurred more rapidly in the LAP than in the OPEN group. The time to clears in the LAP group was a median of 0 days (range, 0-4) vs 3.0 days (range, 2-8) in the OPEN group (p = 0.0001). Time to regular diet was 2.0 days (range, 1-6) in the LAP group vs 5.0 days (range, 3-12) in the OPEN group (p = 0.0001). Length of hospital stay was significantly reduced in the LAP group (4.0 days [range, 2-8], vs 7.0 days [range, 3-14], p = 0.0001). The LAP group had significantly lower direct costs ($8684 vs $11,373) and indirect costs ($1358 vs $2349) than the OPEN group (p < 0.001). This resulted in total costs of $9895 for LAP vs $13,268 for OPEN (p < 0.001). CONCLUSION: Laparoscopic ileocolic resection for CD is feasible. There are significant postoperative benefits in terms of resolution of ileus, narcotic use, and hospital stay. This approach translates into cost savings of >$3300 for laparoscopic patients.
Assuntos
Doença de Crohn/cirurgia , Laparoscopia/métodos , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Estudos de Casos e Controles , Colectomia/economia , Colectomia/métodos , Colite/cirurgia , Custos e Análise de Custo , Doença de Crohn/economia , Estudos de Viabilidade , Feminino , Humanos , Ileíte/cirurgia , Laparoscopia/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoAssuntos
Divertículo do Colo , Doença Diverticular do Colo/classificação , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/fisiopatologia , Doença Diverticular do Colo/cirurgia , Divertículo do Colo/diagnóstico , Divertículo do Colo/etiologia , Divertículo do Colo/fisiopatologia , Divertículo do Colo/cirurgia , Hemorragia Gastrointestinal/cirurgia , Humanos , Hospedeiro Imunocomprometido , Fístula Intestinal/cirurgia , Obstrução Intestinal/cirurgia , Perfuração Intestinal/cirurgia , RecidivaRESUMO
OBJECTIVE: To clarify the true benefits of laparoscopic-assisted colectomy by comparing clinical outcomes from a series of laparoscopic right colectomies with matched open colectomies, all performed for the singular indication of polyp not amenable to colonoscopic removal. PATIENTS AND METHODS: A retrospective case-matched study was performed of consecutive patients undergoing laparoscopic-assisted right hemicolectomy for polyps between January 1992 and July 1997. Each case was matched to a control undergoing the equivalent open procedure for the same indication during the same time period. RESULTS: Thirty-eight patients undergoing laparoscopic-assisted right hemicolectomy for polyps were identified, and matches were found. The conversion rate was 18.4% (7/38), 21.4% early in the series and 10% in later experience. Operative times were longer for laparoscopic-associated colectomy (median, 208 minutes vs 150 minutes, P < .001). Laparoscopic-assisted colectomy resulted in shorter postoperative ileus (time to flatus, 3.0 vs 4.0 days, P < .001; time to bowel movement, 3.5 vs 5.0 days, P < .001) and in earlier tolerance of regular diet (3.5 vs 6.0 days, P < .001). Fewer days of narcotic administration were required by the laparoscopic group (3.0 vs 4.5 days, P < .001). This resulted in a significantly shorter length of hospital stay (4.0 vs 7.0 days, P < .001). There was no significant difference in the incidence of postoperative complications. CONCLUSIONS: Laparoscopic right hemicolectomy has significant patient benefits. These benefits are apparent when procedures of equal complexity and equivalent indications are compared. Laparoscopic-assisted resection has become our preferred approach for polyps not amenable to colonoscopic polypectomy.
Assuntos
Colectomia/métodos , Pólipos do Colo/cirurgia , Laparoscopia , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Perda Sanguínea Cirúrgica , Estudos de Casos e Controles , Colectomia/efeitos adversos , Defecação , Dieta , Feminino , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Fatores de Tempo , Resultado do TratamentoRESUMO
The advanced laparoscopic skills required for laparoscopic resection of the colon and rectum have precluded wide dissemination of this procedure. By applying certain key principles, laparoscopic right hemicolectomy can be made simple, reproducible, easy to teach, easy to learn, and cost-effective.
Assuntos
Colectomia/métodos , Doenças do Colo/cirurgia , Laparoscopia , Humanos , Postura , Reprodutibilidade dos TestesRESUMO
PURPOSE: The aim of this study was to determine rates of complications and extent of benefits for laparoscopic-assisted colectomy compared with open colectomy in patients older than age 75. METHODS: Forty-two patients undergoing laparoscopic-assisted colectomy (1992-1998) were matched to 42 open colectomy patients for gender, age, year of surgery, operating surgeon, and procedure. Health status (American Society of Anesthesiology score), previous abdominal surgery, conversion rate, surgical outcome, and need for assistance at admission and dismissal (independence vs. home with assistance vs. nursing facilities) were reviewed. RESULTS: Mean ages were 81.2 and 80.5 years for laparoscopic-assisted colectomy and open colectomy, respectively (P = not significant). Twenty-one laparoscopic-assisted colectomy and 23 open colectomy patients were females. American Society of Anesthesiology scores were comparable, as were rates of previous abdominal surgery (57 percent for laparoscopic-assisted colectomy vs. 62 percent for open colectomy; P = not significant). Mean operative times were longer for laparoscopic-assisted colectomy (190 minutes for laparoscopic-assisted colectomy vs. 142 minutes for open colectomy; P < 0.001); operating room times progressively decreased from 221 minutes in 1992 to 1995 to 147 in 1998 for laparoscopic right hemicolectomy (P < 0.001). The conversion rate for laparoscopic-assisted colectomy was 14.3 percent. There were no deaths in either group, and laparoscopic-assisted colectomy was associated with fewer morbidities (14.3 percent for laparoscopic-assisted colectomy vs. 33.3 percent for open colectomy; P = 0.04), narcotic usage (2.7 vs. 4.8 days; P < 0.001), time to return to bowel movements (3.9 vs. 5.9 days; P < 0.001), and length of hospital stay (6.5 vs. 10.2 days; P < 0.001). Independent status at admission in 37 laparoscopic-assisted colectomy and 38 open colectomy patients was maintained at discharge by 35 laparoscopic-assisted colectomy vs. 29 open colectomy patients (P = 0.025). CONCLUSIONS: Laparoscopic-assisted colectomy is safe and beneficial, including preservation of postoperative independence, to the elderly when compared with open colectomy.