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500 consecutive laparoscopic colorectal resections with an anastomosis

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31/08/2009

Laparoscopic colorectal surgery - why would you not want to have it and, more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomoses.

Dalton SJ, Ghosh A, Greenslade GL, Dixon AR

Department of Colorectal Surgery, Frenchay Hospital, North Bristol NHS Trust, Bristol, BS16 1LT, UK.

Key words: laparoscopic colorectal surgery, laparoscopic training, complications, ERAS, Lapco

Abstract

Objective: analyse outcome in a consecutive series of 500 unselected patients who underwent elective laparoscopic colorectal resection with anastomosis (ELCRA) under the care of a single surgeon.

Methods: A prospectively collected electronic database of all laparoscopic procedures: April 2001 - September 2008 was analysed.

Results: 500 ELCRAs were performed (230 male, 270 female), mean age 65.6 (range 19-93yrs), ASA grade I (103), II (246), III (145), IV (6). 217 underwent high anterior resection, 131 TMEs (55 covering ileostomies) and 152 right/extended right resections. Indications included: Cancer (340), Diverticular disease (96), Crohn’s disease (40), Polyps (24). Mean operating time was 115 min (35-550min). There were 8 (1.6%) conversions. The mean length of stay was 5.2 days, median 4 days. 93 patients (18.6%) had an inpatient complication; ileus (22), wound infection (14), anastomotic leak (12), enterotomy (2), “off screen” enterotomy (2) abscess (3), ureteric injury (1), cardiac arrhythmia (12), myocardial infarction (5) pulmonary embolus (4), pneumonia (1), C. Difficile (3), retention of urine (9). There were 20 readmissions (4%): ileus (4), retention (3), abscess (2) and leak (2). The 30-day mortality was 9/500 (1.8%); deaths followed anastomotic leaks (3), duodenal enterotomy (1) bleeding DU (1) C Difficile (1) and cardiac (3) complications.

Conclusions: This unselected cohort of patients, the largest single surgeon series from the UK, demonstrates that in trained hands low conversion and complication rates can be consistently achieved. However, if a patient is not fit for discharge at 48hrs – Something is wrong and a laparoscopy is required!

Introduction

Despite Jacobs reporting the first successful laparoscopic colonic resection, a right hemicolectomy in Miami, Florida as long ago as 19901 the uptake of laparoscopic colorectal surgery in the UK has been slow2,3 with only about 18% of ACPGBI surgeons undertaking 50% of their practice laparoscopically2. In the 12-month period to March 2007, 8.82% of resections were performed by this method (NICE 2006)4. Explanations offered for this slow uptake included early concerns about oncological safety 5,6,7 and the recognition of the relatively long and technically demanding learning curve8-11. Large, long-term randomized control trials of laparoscopic surgery for colorectal cancer have supported the view that the original concerns were unfounded (MRC CLASSIC12,COST13 and Barcelona14 trials). Systematic15, Cochrane16 reviews and meta-analysis17 concluded that laparoscopic resection was safe and associated with better short-term outcomes and without any compromise to long-term cancer survival. NICE changed its guidance in 2006 to recommend that NHS trusts gave patients the option of laparoscopic resection as an alternative to open surgery18. Most importantly the guidance recommended that laparoscopic surgery should only be performed by surgeons who have completed appropriate training and who perform this procedure often enough to maintain competence.

Although a number of case series describing single author experience have already been published, the larger of these are very heterogeneous in terms of the types of laparoscopic colorectal procedures carried out19,20; there is also an apparent wide variation in their selection criteria. Exclusion criteria are commonly based on BMI, previous abdominal surgery, location of the lesion and the disease process.

The senior author was trained in laparoscopic colorectal surgery in 1994 and rapidly developed independent experience of its use in benign disease9, often in quite complex cases21-24. Malignant resection was added when we enrolled into CLASSIC. A conscious decision was made in Jan 2002 to make laparoscopic resection the default procedure. This paper describes the short-term results in a consecutive unselected series of 500 patients who underwent a laparoscopic colorectal resection with anastomosis under the care of a single surgeon.

Methods

A prospective electronic database has been maintained for all laparoscopic colonic resections performed by the senior author from April 2001 to September 2008. Consecutive patients requiring colorectal surgery were considered for laparoscopic resection; there were no specific exclusion criteria. Patient demographics, type of resection, location of cancer, stage of the disease, operation time, conversion, and immediate and short-term outcomes were recorded. A conversion was considered to have happened if an unplanned incision (its position and length) had to be made to complete the operation. Surgical technique (3-port using an extended umbilicus incision for specimen extraction), the avoidance of epidurals and our evolving approach of “accelerated” peri-operative care are described elsewhere25.

Instat prism software® was used to test normality of data and to perform analysis. Differences between means of normally distributed variables were assessed by the t test; the Mann Whitney test was used for non-normal data. The patients’ data were held on a password protected, institutionally approved Microsoft Excel database (Microsoft ® Corporation, Redmond, Washington, USA).

Results

500 consecutive, unselected patients underwent laparoscopic colorectal resection with anastomosis (230 males and 270 females) in the study period. The mean age was 65.6 (males 65 female 66) range 19-93. 33 patients were < 40yrs and 224 >70yrs. The mean ASA grade was 2.1, grade I (103), II (246), III (145), IV (6). Mean BMI was 26 (range 14-39). 217 underwent high anterior resections, 131 TMEs; 54 with a covering ileostomy. 152 underwent right/extended right hemicolectomies (table 1).

The indications for surgery were cancer (340), diverticular disease (96), Crohn’s disease (40) and large adenomas (24) (table 2). The average nodal yield in malignant resection was 14.4 (4-39). The mean operating time was 115min (35-550min). A significant reduction of operating time was seen with increasing experience; the first hundred taking a mean of 133 min (95%CI 125-141) and the last hundred 115 min (95%CI 106-124). Supervised trainee mean operating time (from first incision until dressings applied) for matched cases was significantly longer at 123 min. (95%CI 117-134) compared to that of the senior author; 105 min. (95%CI 98-111); p<0.01. The mean operating time in patients with a BMI<25 110min (95%CI 102-119) was significantly less than those with a BMI>25, mean 128min (95%CI 120-132); p<0.001.

8 of 500 operations (1.6%) were converted to an open procedure, with conversion defined as any unplanned incision: bleeding (1), small bowel enterotomy (1) and adhesions (6). There were 21 (4.2%) peri-operative blood transfusions. Most were for pre-existing anaemia; one patient received 10 units following an intra-operative bleed (gonadel vein). The latter only became apparent after release of the pneumoperitoneum for specimen extraction.

Inpatient complications were recorded in 93 patients; post operative ileus (22), wound infection (14), anastomotic leak (12), enterotomy (4), ureteric injury (1), intra-abdominal abscess (3), C Difficile colitis (3), gentamycin nephrotoxicity (1), pneumonia (1), myocardial infarct (5), cardiac arrhythmia (12), PE (4), retention of urine (9) (table 3). The mean length of stay was 5.2 days and a median of 4 days. 47 patients went home within 23 hours of surgery and 135 within 48 hours. 37 were clinically fit for “accelerated” discharge but were delayed for social reasons; this cohort of patients had an average length of stay of 11.7 days.

Twenty patients (4%) were readmitted within 30 days of discharge: ileus (4), retention of urine (3), anastomotic leak (2), wound infection (2), abscess (2), vomiting (2), pancreatitis, faecal impaction, port-site haematoma, diarrhoea and reassurance (table 4). 30-day mortality was 9/500 (1.8%); deaths followed anastomotic leaks (3), bleeding DU (1), duodenal enterotomy (1), C Difficile colitis and cardiac (3) complications. To date, five patients have developed an incisional hernia at the specimen extraction site.

Discussion

Laparoscopic colorectal resection is now established as an acceptable alternative to open surgery and is rapidly gaining in popularity because of its oncological equivalence with the additional advantage of decrease in blood loss, post operative pain, length of stay and an earlier return to full time activity15. That said, its uptake here in the UK has been very slow; a 2007 audit suggesting that only 18% of ACPGBI surgeons used ELCRS in 50 % of their resections2. Here we describe the largest UK single surgeon series of ELCRS including all the cases performed by the training fellows under direct supervision. What’s more, the series is unselected to include “all comers”. We have previously shown no increase in morbidity or mortality in those preceptor cases26, suggesting that in a high volume centre, senior training fellows can gain adequate laparoscopic skills and reach competency relatively quickly.

Restricting the inclusion criteria to exclude those with co-morbidities, previous abdominal surgery, high BMI or bulky tumours limits patient numbers undergoing ELCRS by 40 - 50%27. This case selection however, has in the past had a limited impact on conversion rates28. Centres of Excellence are now reporting that around 90% of patients are suitable for laparoscopic resection29. A meta-analysis30 of 28 studies on 3232 patients demonstrated an overall conversion rate of 15.4%. Our low conversion rate (1.6%) is almost certainly a reflection of our training and “grounding”/experience in complex upper GI laparoscopic surgery, appendicectomy31, TEP hernia repair32 and complex benign colorectal surgery8,21-23 before embarking on ELCRS for cancer. A major finding of this study is that this low conversion rate is carried through into the training cases; our series includes 240 cases where the lead operating surgeon was the training fellow under direct supervision of the senior author. This is particularly important if the UK colorectal community and the ACPGBI in particular, wish to benefit from the hard-learned lesson of ductal injuries that occurred during the uptake of laparoscopic cholecystectomy almost two decades ago. It has certainly been acknowledged by the Department of Health33who have funded the National Training Programme for English surgeons employed in substantive posts. Without a “stick” it remains unclear as yet whether or not English Surgeons will make appropriate use of and exploit this central investment. Some groups11 have produced models to predict which cases are likely to result in a conversion. Whilst laudable, this latter study was based on outcome data collected prior to 2003, since when there have been significant advances in surgical experience and equipment. We maintain that the exclusion criteria applied to previous studies are not necessarily applicable to current practice.

The complication rates described in this report are similar to those previously published19,20. That said, comment needs to be made about the four enterotomies (three during right/extended hemicolectomies) and the divided left ureter which all occurred in the latter half of the series; the senior author made two enterotomies including one “off-screen” incident. Duodenal and DJ flexure enterotomies were repaired laparoscopicaly at the time. The extraction incision was extended (converted) in one case to examine the duodenal repair; a further tiny duodenal enterotomy was still missed. The ureteric injury was seen to have occurred yet not anticipated. It was repaired laparoscopicaly over a ureteric stent and the patient discharged 68hrs later. Serious morbidity followed in three enterotomy patients. The common factor in each case was that patient deterioration/failure to rapidly progress over a weekend period was erroneously put down to “ileus”. In each case an earlier intervention would have resulted in a much more favourable outcome. If a patient is not fit for discharge at 48hrs – Something is wrong and a laparoscopy is required!

The 4-day median length of stay was achieved outside a formal ERAS programme and compares very well to published series where ERAS has been vigorously employed34,35. Basse et al obtained36 what must be considered to be the “holy grail” for ERAS, a median length of stay of 48 hours? Continued refinement of our peri-operative care pathways now allows us to achieve a 48hr discharge in almost three quarters of our patients25. Our 4% readmission rate compares well with other recent series34 and is significantly less than the 12% reported by COST13. It is also of interest that we managed to spot the vast majority of leaks (12/14) and avoid discharging them. One leak only became apparent on day 30. This must allay fears of perhaps more traditional surgical teams who have yet to embrace ERAS.

The fulcrum effect of using a stapler through a port, the limitation in the angulation of currently available staplers and the need for multiple firings are frequently quoted as being limiting factors in allowing laparoscopic low rectal transection37,38,39. Pfannensteil incisions have been used to overcome these perceived problems. An alternative adopted by others is to use a suprapubic port, hand-port or incision. We have learnt through experience that it is possible in all but the largest of tumours and narrowest of pelvises to transect/staple the gut tube low down at the level of the pelvic floor using an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced from the right iliac fossa port using two anterior-posterior firings. The secret is in dissecting/defining the “gut tube” and pelvic floor and more importantly utilising the fulcrum effect by placing the stapler using a fully pronated forearm, flexed wrist and an internally rotated, abducted shoulder. The linear cutter will flex and close at 900 if the tip is pressed against a fixed structure i.e., pelvic side wall/sacrum, a fist placed against the perineum; once the pressure is released it will “return” to 450 and allow firing.

This massive, unselected series is the largest single surgeon series reported from the UK and demonstrates that when minimally invasive surgery becomes the mindset of the whole theatre team, low conversion and complication rates and early discharge can be consistently achieved even whilst preceptoring training fellows. Why would you not want laparoscopic surgery? Laparoscopic colorectal resections are associated with low morbidity and rapid recovery and should be established as the default procedure. Properly structured training is good for patients now and in the future when our properly trained surgeons practice independently. We would consider that failure to embrace the National Training Programme and all that it offers in terms of hard won experience, fool hardy and potentially dangerous.

Acknowledgement

We acknowledge the following who have made substantial contributions to the conduction of this work: Maggie Gregory, Robin Weller, Rhys Davies (Anaesthetists), Fiona Bradden (Data Base) and the following Fellows/SpRs - T Singh Gill, S Pandey, Fiona Court, A Hollowood, Ruth Soulsby, Simone Slawik, Katie Cross, N Kenefick, A Mennon, M Cartmell, L Titu, S Phillips, K Riyad, S Rai and N Zafar

References

1. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1:144-50.

2. Schwab KE, Dowson HM, Van Dellen J, Marks CG, Rockall TA. The Uptake of Laparoscopic Colorectal Surgery in Great Britain and Ireland: A questionnaire survey of consultant members of the ACPGBI. Colorectal Dis 2009; 11: 318-322

3. Harinath G, Shah PR, Haray PN, Foster ME. Laparoscopic colorectal surgery in Great Britain and Ireland--where are we now? Colorectal Dis 2005;7:86-9.

4. NICE implementation uptake report: laparoscopic surgery for colorectal cancer. NICE technology appraisal 105.

http://www.nice.org.uk/media/411/18/ImplUptakeReportColorectalResectionsLaparoscopic.pdf

5. Akle CA. Early parietal recurrence of adenocarcinoma of the colon after laparoscopic colectomy. Port site metastasis after laparascopic colorectal surgery for cure of malignancy. Br J Surg 1996;83:427.

6. Molenaar CBH, Bijnen AB, Ruiter AB. Indications for laparoscopic colorectal surgery. Results from the Medical Centre Alkmaar, The Netherlands. SurgEndosc. 1998; 12: 42-5.

7. Jenkins J, Roth J, Johnson W, Pofahl N. Laparoscopic Colorectal Surgery: Indications and Techniques. Current Surgery, Vol 62, Issue 3, 319 - 323.

8. Pandey S, Slawik S, Cross K, Soulsby R, Pullyblank AM, Dixon AR. Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy? Colorectal Dis 2007;9:536-9.

9.. Choi DH, Jeong WK, Lim SW, Chung TS, Park JI, Lim SB, Choi HS, Nam BH, Chang HJ, Jeong SY. Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience. Surg Endosc 2008.

10. Shah PR, Joseph A, Haray PN. Laparoscopic colorectal surgery: learning curve and training implications. Postgrad Med J 2005;81:537-40.

11. Tekkis PP, Senagore AJ, Delaney CP. Conversion rates in laparoscopic colorectal surgery. A predictive model with 1253 patients. Surg Endosc 2005; 19: 47-54.

12. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM, MRC CLASSIC trial group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718-26.

13. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9.

14. Lacey AM, Garcia-Valdecasas JC, Delgado S et al., Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer; a randomized trial. Lancet 2002; 359: 2224-2229.

15. Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J. Systematic review of laparoscopic versus open surgery for colorectal cancer. Br.J.Surg 2006; 93: 921-8.

16 Schwenk W, Haase O, Neudecker J, Muller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database of Systematic Reviews 2008, Issue 3.

17. Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A, Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E, Pahlman L. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007;142:298-303.

18. National Institute for Health and Clinical Excellence (NICE). Laparoscopic surgery for colorectal cancer. London (UK): National Institute for `health and Clinical Excellence (NICE); 2006 Aug. (Technology appraisal guidance; No. 105). http://www.nice.org.uk/nicemedia/pdf/TA105guidance.pdf

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20. Fukunaga Y, Higashino M, Tanimura S, Takemura M, Osugi H. Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon. Surg Endosc 2008; 22: 1452-8.

21 Gill TS, Karantana A, Rees J, Pandey S, Dixon AR. Laparoscopic proctocolectomy with restorative ileal-anal pouch. Colorectal Dis. 2004 Nov; 6:458-61.

22 Slawik S, Soulsby R, Carter H, Payne H, Dixon AR.Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction.

Colorectal Dis. 2008 Feb; 10(2):138-43

23. Slawik S, Dixon ALaparoscopic reversal Hartmanns rectosigmoidectomy. Colorectal Dis. 2008 Jan;1:81-3.

24. Fowkes L, Krishna K, Menon A, Greenslade GL, Dixon AR. Laparoscopic emergency and elective surgery for ulcerative colitis.

Colorectal Dis. 2008; 4:373-8.

25. Zafar N, Davies R, Greenslade GL, Dixon AR. The evolution of analgesia in an “Accelerated” recovery programme for resectional laparoscopic colorectal surgery with anastomosis. Colorectal Dis. 2009 Jan 16 [Epub ahead of print].

26. SJ Dalton, A Ghosh, N Zafar, K Riyad, AR Dixon. Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective laparoscopic colonic resections with anastomosis.

27. Janson, M., G. Edlund, et al. (2008). "Analysis of patient selection and external validity in the Swedish contribution to the COLOR trial." Surg Endosc. 2008 Dec 5. [Epub ahead of print]

28 NAMES A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350: 2050-9.

29. Buchanan, G. N., A. Malik, et al. (2008). "Laparoscopic resection for colorectal cancer." Br J Surg 95(7): 893-902.

30. Gervaz P, Pikarsky A, Uteh M, Secic M, Efron J, Belin B, Jain A, Wexner S. Converted laparoscopic colorectal surgery. Surg Endosc. 2001 15(8): 827-

31. Duff SE, Dixon AR. Laparoscopic appendicectomy: safe and useful for training. Ann R Coll Surg Engl. 2000 Nov; 82(6): 388-91.

32 Pullyblank AM, Carney L, Braddon F, Dixon AR. Laparoscopic inguinal hernia repair: a NICE operation. J R Coll Surg Edinb. 2002; 47(4):630-3.

33. National training programme in laparoscopic colorectal surgery. www.lapco.nhs.uk

34. King PM, Blazeby JM, Ewings P, Franks PJ, Longman RJ, Kendrick AH, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006; 93: 300-8.

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37 Bergamaschi R, Essani R. Laparoscopic resection for rectal cancer: are we there yet. Colorectal Disease 2009; 11: 1-2

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Table 1. Operations performed

Procedure

No. of patients(%)

High Anterior/Sigmoid Resection

217 (43.4)

TME without ileostomy

77 (15.4)

TME with ileostomy

54 (10.8)

Right /extended right hemicolectomy

152 (30.4)

Total

500

Table 2. Indications for surgery

Pathology

No. of patients (%)

Cancer

340 (68)

Inflammatory bowel disease

40 (8)

Diverticular disease

96 (19)

Adenoma

24 (5)


Table 4. Reasons for readmission

Re-admission reason within 30 days

Number of patients

Ileus

4

Abscess

2

Vomiting

2

Retention of urine

3

Anastomotic leak

2

Wound Infection

2

Vomiting

1

Port site haematoma

1

Reassurance

1

Diarrhoea

1

Pancreatitis

1

Total

20 (4%)

Table 3. Postoperative complications (includes 22 patients with two complications) *Recognised at time of surgery

Complication

No.of patients

Complication

No. of patients

Prolonged ileus

22

Head ache

2

Wound infection

14

ARF

1

Anastomotic leak

12

Pneumonia

1

Enterotomy

4

Haematemesis

1

Abscess

3

Bleeding

1

Myocardial Infarction

5

Incisional hernia

5

AF/LVF/SVT/VF

12

Perforated DU

1

Pulmonary embolism

4

Pelvic Haematoma

2

Retention Urine

9

Phlebitis

1

C difficile

3

UTI

3

Small bowel obstruction

1

Port-site hernia

1

Anastomotic bleed

2

Coagulopathy

3

Ureteric injury*

1

Death

8

Anastomotic stricture

1

Total

93 (18.8%)


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