[Laparoscopic rectal excision for cancer using total mesorectaol excision (TME). Long term outcome of a series of 179 patients]. / Résection rectale pour cancer par laparoscopie avec exérèse totale du mésorectum (ETM). Résultats à long terme d'une série de 179 patients.

BACKGROUND: The purpose of this study was to evaluate the outcomes and the five-year survival of 179 consecutive patients with rectal carcinoma operated with a laparoscopic procedure between April 1992 and April 2003. METHODS: Patients with obstructing, bulky cancers were excluded from this study. Tumor stage was defined according to the TNM classification. Preoperative radiation therapy was offered to T(3) N(0) or N(+) patients (45 Gy). The laparoscopic-assisted technique included total mesorectal excision (TME), primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. All the N+ patients received adjuvant chemotherapy. The outcomes were defined as five-years recurrence (local recurrence and distant metastasis) and the diseases-free survival. The survival rates were calculated with the Kaplan-Meier test. RESULTS: There were 108 males and 71 females, median age was 67 (range 39-88). There were 61 upper rectum localizations (34%), 68 middle rectum (38%) and 50 low rectum (28%). Twenty-nine patients required open conversion (16%). Surgical operative morbidity was 24% and medical morbidity was 4%. There were 60 stage I (40%), 25 stage II (16%), 49 stage III (32%), and 16 stage IV (10%). Ninety patients (71%) are alive and disease free, ten (5%) are alive with disease recurrence, and 37 patients (20%) are deceased. Only one case of trocar site implantation occurred after curative resection during an average follow up of 76 months. Five-year observed survival rate were 85% for stage I, 70% for stage II, and 63% for stage III. CONCLUSION: In our experience laparoscopic rectal resection could be done safely. The oncologic outcome was similar to that of open surgery. Further randomized trials will be necessary to confirm the value of this technique.

Laparoscopic left colon resection for diverticular disease.

BACKGROUND: The aim of this study was to review our experience with laparoscopic sigmoid colectomy for diverticular disease. METHODS: All patients presenting with acute or chronic diverticulitis, obstruction, abscess, or fistula were included. Symptomatic diverticular disease was the main surgical indication (95%). RESULTS: Between March 1992 and August 1999 170 consecutive patients underwent surgery. Of these, 21 patients (12%) had significant obesity, with body mass index (BMI) greater than 30. The average length of surgery was 141 +/- 36 min. In 163 patients (96%), the procedure was performed solely with the laparoscope. The nasogastric tube was removed on postoperative day 2 +/- 1.9, and oral feeding was started on postoperative day 3.4 +/- 2.1. The average length of hospital stay after surgery was 8.5 +/- 3.7 days. During the first postoperative month, there were no deaths. However, 11 patients (6.5%) had surgical complications: 5 anastomotic leaks (2.9%), 1 intraabdominal abscess (0.6%), and 3 wound infections (1.7%). There were four reinterventions (2.4%), with two diverting colostomies. Secondarily, 10 anastomotic stenoses (5.9%) were observed. Eight patients required a reintervention: seven anastomotic resections by open laparotomy and one terminal colostomy. Seven patients (4.1%) reported retrograde ejaculation, and one reported impotence. CONCLUSIONS: The feasibility of the laparoscopic approach to diverticular disease is established with a conversion rate of 4%, a low incidence of acute septic complications (5.3%), and a mortality rate of 0%. Therefore, laparoscopic sigmoid colectomy has become our procedure of choice in the treatment of diverticular disease.