Converted laparoscopic colectomy: what are the consequences?

BACKGROUND: The safety and benefits of laparoscopic colon resection are well documented. However, few reports have addressed the safety and comparative outcome of laparoscopic colon operations that necessitated conversion. METHODS: All consecutive laparoscopic colon resections performed by a single surgeon from July 1996 to October 2003 were assessed. Data obtained from a prospective computerized database included demographics, diagnosis, reason and time to conversion, length of stay, morbidity, and mortality. Additionally, all laparoscopic-converted colectomies were then matched with open colectomies by diagnosis and severity of disease and analyzed with respect to morbidity, mortality, and clinical outcome. RESULTS: A total of 143 laparoscopic colon resections were analyzed, 78 of which were left colon resections and 65 were right colon resections. The overall conversion rate was 19.6% (28 patients). The disease entities of the 28 converted patients were diverticulitis (16), polyps (four), Crohn's disease (three), metastatic cancer (three), and others (two). Conversion was higher in the left-sided (24 patients, 30.8%) versus right-sided (four patients, 6.1%) procedures. There were no differences regarding age, gender, and comorbidities among the laparoscopic, open, and converted groups; the median follow-up was 39 months. The median length of stay was 6, 8, and 12 days for the laparoscopic, open, and converted groups, respectively. Right-sided conversions were due to the size of the inflammatory mass in three patients and intraoperative bleeding in one patient. Left-sided conversions were due to the inflammatory process extending beyond the sigmoid colon in 12 patients, adhesions in five, obesity in four, pericolonic abscess in two, and fixed mass in one patient. Postoperative morbidity was significantly higher for laparoscopic procedures that were converted to open procedures more than 30 min into the operation. Preoperative predictors of conversion were extent of inflammatory process beyond the sigmoid colon and obesity, whereas intraoperative predictors were adhesions and bleeding. CONCLUSIONS: Laparoscopic-converted colon resection is associated with significantly greater morbidity, particularly wound complications and greater length of hospital stay, compared to open or laparoscopic colectomies. Prompt conversion (<30 min) may reduce the overall morbidity associated with converted procedures. Furthermore, thoughtful patient selection may decrease the conversion rate and thereby prevent the inherent morbidity associated with converted procedures.

The influence of cigarette smoking on cytokine levels in patients with inflammatory bowel disease.

Anecdotal reports suggest that smoking may be beneficial for patients with inflammatory bowel disease (IBD) as nicotine may act through inflammatory mediators within the colonic mucosa. Furthermore, there is increasing evidence that cytokines play a pathologic role in IBD. Our aim was to determine the effects of cigarette smoking on cytokine levels in the colonic mucosa of patients with and without IBD. Mucosal biopsies were obtained from 10 patients with Crohn's disease (CD), 10 with ulcerative colitis (UC), and 10 healthy controls. Five of 10 patients in each of the three groups were smokers and five were nonsmokers. Concentrations of interleukin (IL)-1beta, IL-2, IL-6, and IL-8 were determined using enzyme-linked immunosorbent assay (ELISA). Cytokine levels of smokers were compared with nonsmokers in each group and with controls. Results were analyzed using the Mann-Whitney test; significance was set at p<0.05. The concentration of IL-8 was significantly higher in healthy controls who smoke compared with nonsmokers and significantly reduced in smokers with CD compared with nonsmokers with CD. Moreover, concentrations of IL-1beta and IL-8 were significantly reduced in smokers with UC compared with nonsmokers with UC. Smokers had significantly elevated levels of IL-8 in the colonic mucosa. Smokers with IBD had a significant reduction in cytokine levels; specifically, IL-1beta and IL-8 for patients with UC and IL-8 for patients with CD. Further studies are warranted to determine if this reduction in cytokine levels is histologically and clinically significant.

Surgical patients with pseudomembranous colitis: factors affecting prognosis.

BACKGROUND: Although several studies have identified the factors that contribute to the development of antibiotic-associated colitis (AAC), little data are available in regard to those factors that may affect the prognosis of patients with the disease. Therefore we conducted a retrospective analysis of 201 surgical patients with AAC to identify risk factors predictive of increased morbidity or mortality. METHODS: We conducted a review of the charts of 201 surgical patients hospitalized between Jan. 1, 1991, and June 30, 1993, in whom AAC developed. AAC was defined as the presence of diarrhea associated with a positive latex agglutination or toxin assay for Clostridium difficile. An additional 52 procedure-matched charts of patients admitted to a surgical service during the same period were also reviewed and constituted the control group. We analyzed the contribution of 21 variables to prognosis in both groups. RESULTS: There was no difference between the two groups in the preoperative length of stay, the number of antibiotics per patient and the number of antibiotic-days, number of patients receiving preoperative bowel preparation, total parenteral nutrition, and overall mortality rate. Patients in the control group were at increased risk of death if they had a history of preexisting renal dysfunction, prolonged preoperative hospital stay, and a poor nutritional status. AAC developed 10.0 +/- 13.8 days after operation in the study group. All patients were receiving multiple antibiotics at the time of diagnosis (3.6 +/- 7.5 antibiotic), with a mean of 14.3 +/- 20.7 antibiotic-days. The overall mortality rate in the study group was 8%. In five patients (2%) toxic megacolon developed; four deaths occurred among these patients (80% mortality rate). A 25% mortality rate was directly attributable to complications of AAC. Six variables were identified as predictive of increased mortality rate: steroids, laxatives, length of preoperative stay, postoperative interval before the onset of symptoms, use of total parenteral nutrition, and abdominal distention. CONCLUSIONS: AAC carries a significant mortality rate in surgical patients; therefore the diagnosis of AAC should be aggressively pursued and patients with the disease should be promptly treated. Patients receiving steroids, total parenteral nutrition, and multiple antibiotics in whom signs and symptoms of AAC develop late in their postoperative course, and patients with abdominal distention and marked leukocytosis, are at increased risk of dying of AAC and should be aggressively treated.

Cytokines in Crohn's colitis.

BACKGROUND: Increasing evidence points to a pathologic role for cytokines in Crohn's colitis. Levels of cytokines are increased in diseased segments of colon in Crohn's colitis, but no one has studied the concentration of cytokines in clinically and histologically nondiseased segments. METHODS: Mucosal biopsies were obtained from 7 patients with active segmental Crohn's colitis and from 7 controls without inflammatory bowel disease. The concentration of Interleukin (IL)-1 beta, IL-2, IL-6, and IL-8 in patients and controls were determined using enzyme linked immunosorbent assay and compared. Histologic sections were also performed to confirm diseased and nondiseased segments of colon. RESULTS: The concentrations of IL-1 beta, IL-6, and IL-8 were significantly higher in the involved segments of colon (10.3 +/- 4.1, 3.7 +/- 1.0, 34.4 +/- 6.9 picograms [pg] per mg) when compared to controls (1.8 +/- 0.5, 1.1 +/- 0.5, 5.3 +/- 1.0 pg/mg). The concentrations of IL-1 beta, IL-2, and IL-8 (8.5 +/- 2.9, 5.3 +/- 1.2, 26.3 +/- 8.8 pg/mg) in normal appearing segments of colon of patients with Crohn's colitis were also significantly higher than in controls, whose IL-2 level was 2.0 +/- 0.5 pg/mg. IL-1 beta and IL-8 were significantly more concentrated in both the involved and uninvolved colonic segments of patients with Crohn's colitis compared to controls. IL-2 and IL-6 were also more concentrated in Crohn's patients than in controls, but not significantly. The differences in interleukin concentrations between involved and uninvolved segments of colon in patients with segmental Crohn's colitis were not significant. CONCLUSIONS: Although Crohn's colitis is often a segmental disease, concentrations of IL-1 beta and IL-8 are increased throughout the entire colon. These observations reinforce the hypothesis that Crohn's colitis involves the whole colon even when this is not apparent clinically or histologically.

Radiation-induced enteropathy.

The incidence of chronic radiation enteritis appears to have risen in recent years due to the increasing utilization of radiotherapy for abdominal and pelvic malignancies. The etiology, pathogenesis, and management of radiation enteritis are discussed. Two case reports exemplify the progressive nature of the disease. Case 1 demonstrates the classical picture of multiple exacerbations and remissions of partial small bowel obstruction and the eventual need for surgical management ten years after radiation therapy. Case 2 presents the more severe sequelae of an acute perforation with a 14-yr latency period. Predisposing factors in the progression of radiation injury include excessive radiation, underlying cardiovascular disease, fixation of the bowel, and an asthenic habitus. In both cases, radiation injury was localized to a discrete segment of bowel; therefore, resection with a primary end-to-end anastomosis was performed. In addition, diseased bowel was eliminated and, therefore, would not cause further complications such as intractable bleeding or fistula formation. The review focuses on current knowledge which may be applied to the treatment and prevention of radiation enteritis.

Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach.

The surgical management of rectovaginal fistulas complicating Crohn's disease has been associated with unacceptably high failure rates. We sought to modify the available surgical techniques to provide a solution to this challenging problem. Between December 1983 and January 1990, 14 patients with Crohn's disease underwent repair of a rectovaginal fistula. A modified transvaginal approach was employed by the authors. A diverting loop ileostomy was performed on all patients, either as the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. The fistula was completely eradicated in 13 of the 14 women and did not recur during the mean follow-up period of 55.0 months (range, 3-77 months). Intestinal continuity was reestablished in these 13 patients within 6 months after the initial fistula repair. One patient with a very low-lying fistula constituted our only failure. We have found the transvaginal method preferable to the transanal approach because of the relative ease in raising the vaginal flap as compared with a flap of fibrotic and inflamed anorectal mucosa. On the basis of this study, we conclude that a modified transvaginal approach is an effective method for repair of rectovaginal fistulas secondary to Crohn's disease.

Transvaginal approach for repair of rectovaginal fistulae complicating Crohn's disease.

The management of rectovaginal fistulae complicating Crohn's disease is difficult and often unsatisfactory. Between December 1983 and November 1988, 13 patients with Crohn's disease underwent repair of rectovaginal fistulae via a transvaginal approach. All patients had a diverting intestinal stoma either as part of the initial step in the staged management of intractable perianal disease or concurrent with the repair of the rectovaginal fistula. Each of the patients had low or mid septal fistulae; high fistulae generally are treated transabdominally and are not the focus of this discussion. Fistulae were eradicated in 12 of the 13 women and did not recur during the follow-up period, which averaged 50 months (range, 9 to 68 months). The only treatment failure was a patient who had a markedly diseased colon from the cecum to the rectum and a very low-lying fistula. It is concluded that a modified transvaginal approach is an effective method for repair of rectovaginal fistulae secondary to Crohn's disease.

Low Hartmann's procedure for severe anorectal Crohn's disease.

Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistulas, necessitating excisional surgery, underwent a low Hartmann's procedure in lieu of a standard proctectomy. Fifteen of the 25 (60 percent) patients had a completely healed perineum and required no further surgical therapy. Although perineal disease persisted in the other 10 patients, their perinea were much improved compared with the initial presentation. Following a low Hartmann's procedure, the rectal stump becomes atrophic and anoperineal disease regresses, thereby permitting subsequent perineal proctectomy in less inflamed tissues. Since only a 3-cm to 5-cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an unhealed perineum. Twenty-two of the 25 (88 percent) patients have a completely healed perineum (mean follow-up period, 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the problem of the unhealed perineal wound can be averted with this approach, thereby reducing the long-term morbidity to the patient.

Morbidity of medical therapy for ulcerative colitis: what are we really saving?

AIM: The true morbidity, cost and disability of medical therapy for ulcerative colitis are seldom delineated and are even less frequently compared to analogous parameters associated with surgical therapy. Therefore, we sought to assess and contrast medical versus surgical therapy for patients hospitalized due to severe ulcerative colitis. MATERIALS AND METHODS: Patients were matched for age, duration and severity of disease based upon Truelove and Witts' activity index, colonoscopic and histologic appearance and APACHE (Acute Psychological and Chronic Health Evaluation) II scores. Morbidity, cost and disability of 20 medically treated patients who required at least one hospital admission were compared to 20 patients treated by a three stage restorative proctocolectomy. Demographic data, number of hospital admissions, length of stay, total hospital charges including consultant's, surgeon's, and anesthesiologist's fees, morbidity of each approach and disability were assessed. Statistical analysis was performed using Mann-Whitney and Fisher exact tests. Significance was considered as P < 0.05. RESULTS: The mean age was 53.6 years in the medical group and 48.1 years in the surgical group (P = NS) and the average duration of disease was 10.5 years and 9.5 years, respectively (P = NS). The same severity of pancolitis was noted in both groups; APACHE scores of 13 and 14 in the medical and surgical groups, respectively, were noted. The total number of hospital admissions and total combined length of stay per patient in each group were not significant. Total mean hospital cost for the medical group was $28,477.00 per patient versus $33,041.00 for the three stage restorative proctocolectomy (P = NS). The mean duration of disability in the medical group was 6.4 months per patient versus 5.0 months in the surgical group (P = NS). However, patients in the medical group required more transfusions (25%) than did those in the surgical group (0%) (P < 0.05) and significant weight loss was more common in the medical group (45%) compared to the surgical group (5%) (P < 0.01). All patients in the surgical group were permanently weaned from steroids. Furthermore, while 65% of patients in the medical group had significant steroid-related complications, the major surgical complication rate was only 15% (P < 0.01). CONCLUSION: Medical treatment was associated with a significantly higher overall morbidity than surgical therapy. Additionally, a three stage restorative proctocolectomy was performed at no additional hospital cost or subsequent disability in patients with severe ulcerative colitis. The value of prolonged medical therapy in this select group of patients is questionable.

Laparoscopic surgery for diverticulitis.

BACKGROUND: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. METHODS: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p = NS). RESULTS: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). CONCLUSION: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment.