Laparoscopic sigmoid resection for acute and chronic diverticulitis. An outcomes comparison with laparoscopic resection for nondiverticular disease

Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease

Background and Objectives:

The role for the robotic-assisted approach as a minimally invasive alternative to open colorectal surgery is in the evaluation phase. While the benefits of minimally invasive colorectal surgery when compared to the open approach have been clearly demonstrated, the adoption of laparoscopy has been limited. The purpose of this study was to evaluate clinical outcomes, hospital and payer characteristics of patients undergoing robotic-assisted, laparoscopic, and open elective sigmoidectomy for diverticular disease in the United States.

Methods:

This is a retrospective propensity score–matched analysis. The Premier Healthcare Database was queried for patients with diverticular disease. Patients with diverticular disease who underwent robotic-assisted, laparoscopic, and open sigmoidectomy for diverticular disease from January 2013 through September 2015 were included. Propensity-score matching (1:1) facilitated comparison of robotic-assisted versus open approach and robotic-assisted versus laparoscopic approach. Peri-operative outcomes were assessed for both comparisons.

Results:

There were several outcomes advantages for the robotic-assisted approach when compared to laparoscopic and open sigmoidectomy for diverticular disease that included significantly fewer conversions to open (P = .0002), shorter hospital length of stay, fewer postoperative complications—ileus, wound complications, and acute renal failure—and more patients discharged directly to home.

Conclusions:

The robotic-assisted minimally invasive approach to elective sigmoidectomy for diverticular disease results in favorable intra-operative and postoperative outcomes when compared to laparoscopic and open approaches.

Laparoscopic sigmoidectomy in moderate and severe diverticulitis: analysis of short-term outcomes in a continuous series of 121 patients

BACKGROUND

The role of laparoscopic surgery has been shown to be safe, feasible, and equivalent to open surgery for moderate diverticulitis, but its role in severe disease is still being elucidated. The aim of this study was to compare short-term outcomes in patients who underwent laparoscopic sigmoidectomy for moderate and severe diverticulitis.

METHODS

All patients who had elective laparoscopic sigmoidectomy for diverticulitis between April 2003 and September 2011 at the University Hospital of Luxembourg were selected from a retrospective database. The patients were divided in two groups: moderate acute diverticulitis (MAD) included patients with an episode of left-lower-quadrant pain, elevated inflammatory markers, and radiologic evidence of diverticulitis, and severe acute diverticulitis (SAD) included patients with diverticula associated with abscess, phlegmon, perforation, fistula, obstruction, bleeding, or stricture.

RESULTS

A total of 121 patients (81 MAD and 40 SAD) underwent elective laparoscopic sigmoidectomy with primary anastomosis. There were no significant differences between the two groups with respect to demographic characteristics, except for sex ratio. In this series the overall morbidity rate at 30 postoperative days (POD) was 12.4 %, with no significant differences between MAD and SAD (16.0 vs. 5 %, respectively; P = 0.083). No significant differences were found with respect to mean length of hospital stay (6.7 vs. 7.7 days; P = 0.399) as well. The overall conversion rate to open surgery was 2.5 % (3 patients), with no difference between the two groups. Conversion to laparotomy was associated with an increased morbidity rate (11.0 % for full laparoscopy vs. 66.6 % for conversion; P = 0.040) and a longer length of stay (6.8 vs. 16.7 days; P = 0.008). There were no deaths within 30 POD.

CONCLUSIONS

Elective laparoscopic sigmoidectomy is safe and feasible for patients with moderate and severe acute diverticulitis and the outcomes are equivalent.

Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review

AIM

A meta-analysis of nonrandomized studies and one randomized trial was conducted to compare laparoscopic surgery with open surgery in the elective treatment of patients with diverticular disease.

METHOD

Published randomized and controlled clinical trials that directly compared elective open (OSR) with laparoscopic surgical resection (LSR) in patients with diverticular disease were identified using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. End-points included 30-day mortality and morbidity and were compared by determining the relative risk ratio, odds ratio, and the absolute effects.

RESULTS

Eleven nonrandomized studies of 1430 patients were identified and included in the meta-analysis. There was only one randomized study, which included 104 patients. The meta-analysis suggested that elective LSR was a safe and appropriate option for patients with diverticular disease and was associated with lower overall morbidity (P = 0.01) and minor complication rate (P = 0.008).

CONCLUSION

The results of the nonrandomized study generally agreed with those of the randomized study, except for the incidence of minor complications, which was higher in both the LSR and OSR groups of the randomized study. In this study, the high overall morbidity of 42.3% reported in the LSR group is a cause for concern.

Colorectal surgery in a community hospital setting: have attitudes changed because of laparoscopy? A general surgeons' last 5 years experience review

INTRODUCTION

Laparoscopy is rapidly emerging as the preferred surgical approach to a number of different diseases because it permits a correct diagnosis and accurate treatment; however, it is not yet being applied in a widespread manner in the management of benign or malignant colorectal disease. The aim of this work is to illustrate retrospectively the results of our experience of laparoscopic colorectal surgery carried out in a community hospital over the last 5 years to document its feasibility, safety, and benefits when carried out by general surgeons in this setting.

MATERIALS AND METHODS

Between January 2003 and December 2007 a total of 628 patients underwent a colorectal procedure. Among them, 328 (52.2%) were operated on with a laparoscopic approach.

RESULTS

In 12 cases, we had to convert to the open approach. Major complications occurred in 3.6% whereas minor occurrences occurred in up to 10%.

CONCLUSIONS

Even if limited by its retrospective design, our experience exhibits that the laparoscopic may well be a safe and effective approach to colon pathology in a community hospital setting. Such features make laparoscopy a challenging alternative to open surgery in the approach to colon disease and it can be proven to be cost-effective without undue risk, as long adequate laparoscopic training is undertaken by the surgeon and proper preparation observed.

Laparoscopy for benign colorectal diseases

The applicability of laparoscopy to many complex intraabdominal colorectal procedures continues to expand, and has been shown to be feasible and safe in experienced hands. Data are available on the elderly, rectal prolapse, diverticulitis, Hartman's takedown, small bowel obstruction, Crohn's disease, and ulcerative colitis. Clinically relevant advantages have been clearly demonstrated in selected patient populations. Laparoscopic surgery for benign colorectal disease should be considered in patients suitable for this approach to an abdominal operation.

Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006

PURPOSE

This study was designed to compare outcomes after elective laparoscopic and conventional colorectal surgery over a ten-year period using data from the English National Health Service Hospital Episode Statistics database.

METHODS

All elective colonic and rectal resections carried out in English Trusts between 1996 and 2006 were included. Univariate and multivariate analyses were used to compare 30 and 365-day mortality rates, 28-day readmission rates, and length of stay between laparoscopic and open surgery.

RESULTS

Between the study dates 3,709 of 192,620 (1.9%) elective colonic and rectal resections were classified as laparoscopically assisted procedures. The 30-day and 365-day mortality rates were lower after laparoscopic resection than after open surgery (P < 0.05). After correction for age, gender, diagnosis, operation type, comorbidity, and social deprivation, laparoscopic surgery was a strong determinant of reduced 30-day (odds ratio, 0.57; 95% confidence interval, 0.44-0.74; P < 0.001) and one-year (odds ratio, 0.53; 95% confidence interval, 0.42-0.67; P < 0.001) mortality. Similarly, multivariate analysis confirmed that laparoscopic surgery was independently associated with reduced hospital stay (P < 0.001). Patients who received rectal procedures for malignancy, however, were more likely to be readmitted if laparoscopy rather than by a traditional method was used (11.9% vs. 9.1%, P = 0.003).

CONCLUSION

In the present study, patients selected for laparoscopic colorectal surgery were associated with reduced postoperative mortality when compared with those undergoing the conventional technique. This finding merits further investigation.

Chronic diverticulitis: clinical, radiographic, and pathologic findings

OBJECTIVE

The purpose of our study is to present a series of 14 patients with chronic diverticulitis on barium enema examinations and to correlate the radiographic findings with the clinical and pathologic findings in these patients.

CONCLUSION

Chronic diverticulitis is a distinct pathologic entity characterized by the frequent development of chronic obstructive symptoms and abdominal pain rather than the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the basis of the characteristic clinical and radiographic findings in these patients.

A single training center's experience with 200 consecutive cases of diverticulitis: can all patients be approached laparoscopically?

BACKGROUND

This study aimed to evaluate the outcomes for consecutive patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy.

METHODS

Data for this patient population were collected by chart review and analyzed retrospectively.

RESULTS

Between December 2001 and March 2007, 200 consecutive patients (93 men and 107 women) with an average age of 55 years were identified. All cases were managed by one of two colorectal surgeons. Of the 200 patients, 158 had recurrent diverticulitis, 20 had fistulas, 12 had abscesses, 8 had strictures, 1 had a mass, and 1 had a bleed. The mean operative time was 159 min, and the conversion rate was 8%. A total of 30 early postoperative complications occurred for 26 patients including wound infection (n = 9), ileus (n = 8), Clostridium difficile colitis (n = 3), urinary retention (n = 3), pelvic abscess (n = 2), deep vein thrombosis and pulmonary embolism (n = 1), pneumonia (n = 1) urinary tract infection (n = 1), anastomotic leak (n = 1), and small bowel obstruction (n = 1). Late complications experienced by 11 patients included Clostridium difficile colitis (n = 3), incisional hernia (n = 3), wound infection (n = 3), wound hematoma (n = 1), and intraabdominal hemorrhage (n = 1).

CONCLUSIONS

The authors believe it is feasible to offer elective laparoscopic sigmoid colectomy to all patients with symptomatic diverticular disease despite preoperative risk factors.

Polybacterial pyomyositis following laparoscopic colectomy for complicated diverticulosis

We report a case of diffuse subacute muscle infection caused by enteric bacteria, diagnosed two months after laparoscopic colectomy for a sigmoid abscess and successfully treated with antibiotics alone.

Comparison of laparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003-2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 +/- 6.4 vs 7.8 +/- 6.6 days) and in the benign laparoscopic groups (5.1 +/- 3.5 vs 7.2 +/- 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease.

Minilaparoscopic colorectal resection: a preliminary experience and an outcomes comparison with classical laparoscopic colon procedures

BACKGROUND

Laparoscopy has rapidly emerged as the preferred surgical approach for a number of different diseases because it allows for a correct diagnosis and proper treatment. However, it is not being applied in a widespread manner for the management of benign or malignant colorectal disease. Its natural evolution seems to be the development of mini-instruments and optics (diameter, </=5 mm). This study aimed to illustrate retrospectively the results of an initial minilaparoscopic colorectal surgery experience at two different institutions.

METHODS

Between January 2001 and December 2006, a total of 517 patients underwent a laparoscopic colon procedure. Among them, 161 (31.1%) underwent surgery with mini-instruments. The primary end point was the feasibility rate for minilaparoscopic colon resection. The secondary end points were safety and the impact of the technique on the duration of laparoscopy.

RESULTS

No conversion to classical laparoscopy and eight cases converted to the open approach were registered. The rate for major complications was 3.1%, whereas the rate for minor complications ranged as high as 11.8%.

CONCLUSIONS

Even if limited by its retrospective design, the reported experience shows that minilaparoscopic surgery may be a safe and effective approach to colon pathology. The described features make minilaparoscopy a challenging alternative to laparoscopy for colon disease. If proven to be cost effective without undue risk, as long as adequate training is obtained and proper preparation is observed, minilaparoscopy may become a standard surgical approach for selected patients.

The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis

Backround

Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.

Method

Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.

It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.

Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.

Discussion

The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.

French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease

BACKGROUND

The aim of this study was to compare in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD).

METHODS

This prospective national multicentre observational study included all consecutive patients undergoing open or laparoscopic elective colectomy for SDD in a 4-month period between June and September 2002. Postoperative in-hospital mortality and morbidity in the two groups were compared.

RESULTS

Three hundred and thirty-two consecutive patients undergoing either laparoscopic (163 patients) or open (169 patients) colectomy for SDD were analysed. Overall postoperative mortality and morbidity rates were 0.3 and 23.8 per cent respectively. The morbidity rate was significantly higher in the open than in the laparoscopic group (P < 0.001), leading to a significantly longer hospital stay (P < 0.001). The morbidity rate remained significantly higher in the open group when the patients were matched for age (P = 0.015) or American Society of Anesthesiologists score (P = 0.028). An open procedure (relative risk (RR) 2.13 (95 per cent confidence interval (c.i.) 1.29 to 3.45)), age over 70 years (RR 1.62 (95 per cent c.i. 1.14 to 2.30)) and intraperitoneal contamination (RR 2.54 (95 per cent c.i. 1.18 to 5.50)) were identified as independent risk factors for morbidity.

CONCLUSION

A laparoscopic approach to elective treatment of SDD may be associated with reduced postoperative morbidity and hospital stay. A randomized study is required to confirm these results.

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Laparoscopic sigmoid colectomy for diverticular disease

Laparoscopic management of sigmoid diverticular disease has emerged as an important adjunct to the armamentarium of surgical options for this disease process. Although there are no prospective randomized studies directly comparing laparoscopic and open colectomy for diverticulitis, the comparative studies provide compelling data. The magnitude of benefits achieved with laparoscopic colectomy in the hands of experienced laparoscopic colon surgeons may soon be sufficient to make laparoscopic colectomy the standard of care.

Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared with non-diverticular disease

BACKGROUND AND AIMS

It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.

PATIENTS AND METHODS

All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p<0.05 was considered statistically significant).

RESULTS

A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p>0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p>0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p>0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p>0.05).

CONCLUSION

These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Laparoscopic TME: better vision, better results?

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

Laparoscopic sigmoidectomy for fistulized diverticulitis

PURPOSE

Nowadays laparoscopic colorectal surgery has demonstrated its advantages, including reduced postoperative pain, decreased duration of ileus, and shorter hospital stay. Few studies report results of laparoscopic surgery in complicated diverticulitis. This study was designed to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis.

METHODS

The authors retrospectively reviewed 16 patients who had laparoscopic sigmoidectomy for fistulized diverticulitis between 1992 and 2003 in a series of 247 laparoscopic colectomies. Eleven patients presented with colovesical, four with colovaginal, and one with colocutaneous fistulas; all were caused by sigmoiditis. The procedure always consisted of celioscopic sigmoidectomy with stapled transanal suture and, when indicated, closure of the cystic or vaginal fistula orifice.

RESULTS

Mean age was 60 (range, 39-78) years. Mean number of episodes of diverticulitis before operation was three (range, 1-5). Mean time between the last episode and operation was 46 (range, 2-250) weeks. In our first three years of experience, three cases (18.7 percent) were converted to laparotomy. Reasons for conversion were the necessity for intestinal resection, splenectomy, and a wound of the anterior rectum. The mean operative time was 172 (range, 100-280) minutes. Mean hospital stay was 5.7 (range, 3-12) days. There was no mortality. Postoperative morbidity (2 patients, 12.5 percent) consisted of one pulmonary infection and one splenectomy. Long-term follow-up revealed no recurrence of diverticulitis and one incisional hernia.

CONCLUSIONS

In experienced hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

Impact of diverticular disease on hospital costs and activity

BACKGROUND

Diverticulosis is very common in the UK and patients with clinically significant diverticular disease present regularly to departments of surgery as acute emergencies or chronic problems. There are no national data on the hospital prevalence, clinical implications or financial impact of diverticular disease hence the extent of the clinical problem is as yet not quantified.

AIM

To detect the prevalence, clinical implications and financial impact of diverticular disease over a one year period in a large district hospital.

METHODS

Retrospective review of all patients treated for diverticular disease during one financial year. Clinical and cost analysis of inpatient and outpatient investigations, treatment and hospitalization.

RESULTS

A total of 148 patients were treated of whom 83 were admitted for more than 1 day, 55 of those were emergency admissions. Five of 83 admitted patients died (in-patient mortality 6%, peri-operative mortality 26.3%). There was a total number of 982 hospitalization days of which 94 Intensive Care Unit days and 68 High Dependency Unit days. Nineteen operations were performed (16 sigmoid colectomies, 1 oversewing of perforated sigmoid, 2 reversal of colostomy). The investigations generated were 48 colonoscopies, 77 flexible sigmoidoscopies, 77 Barium enemas, 2 CT scans and 34 ultrasound scans. A total number of 410 clinic appointments were generated. One year after discharge 134/148 (90.5%) patients were alive. The total cost of this activity was pound 465263 or 5.3% of the total annual budget for General Surgery. Seventy percent of the cost was bed-days expenses with ICU hospitalization accounting for 25% of the total cost.

CONCLUSION

Diverticular disease is a major cause of morbidity in a large district hospital and a significant burden on resources. More research should be done on prevention of complications and management in the community. The current methods of management do not appear to be cost-effective and attempts should be made to produce protocols for evidence-based, cost-efficient management of the disease. A UK national audit should be undertaken.

Laparoscopic Versus Open Sigmoid Colectomy for Diverticulitis

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 ( P < 0.001). Mean operative times were: laparoscopic group, 170 ± 45 minutes; open group, 140 ± 49 minutes ( P < 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively ( P < 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy ( P < 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were $25,700 for open sigmoid colectomy and $17,414 for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.

Care of the laparoscopic colectomy patient

Laparoscopic bowel surgery has demonstrated patient care benefits of decreased duration of hospital stay, smaller incisions, lower risk of cardiopulmonary complications, and reduced risk of small-bowel obstruction. Resection of complicated diverticular disease and inflammatory bowel disease can be technically challenging and may be associated with higher conversion rates. The applicability of these techniques to colon cancer is supported by a growing body of evidence that demonstrates similar survival and recurrence rates obtained by open resection and the exaggeration of the risk of port site recurrences. Laparoscopic colorectal surgery has also challenged much of the standard postoperative care plans used for colectomy. Optimal postoperative care of the laparoscopic colectomy patient requires an appreciation of the faster recovery enjoyed by these patients and the fact that ambulation and dietary advancement need to be accelerated. Coordination between the surgical team and the postoperative care team is essential to obtain all the benefits associated with this new approach to the management of colorectal disease.

Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease

PURPOSE

The feasibility of laparoscopic colectomy for colon surgery has now been well established. Most of the studies on laparoscopic colectomies include all types of colonic pathologies without discrimination. Our goal was to compare laparoscopic sigmoid colectomy open sigmoid colectomy for simple sigmoid diverticular disease, to assess whether it can be done safely and whether the proposed advantages could be realized.

METHODS

We evaluated the differences in outcomes of 66 laparoscopic sigmoid colectomy patients and 88 open sigmoid colectomy patients. We report a five-year outcomes analysis of 154 patients undergoing sigmoid colectomy for diverticular disease. We compared age, gender, history of prior abdominal surgery, estimated blood loss, operative time, total conversions with reason for conversion, time until a liquid diet was started, postoperative complications, hospital length of stay, operation costs, and total hospital charges incurred for both laparoscopic sigmoid colectomy and open sigmoid colectomy.

RESULTS

Mean age and gender were similar in the two groups. However, the mean estimated blood loss (143 ml 314 ml), time until a liquid diet was started (2.9 4.9 days), and hospital length of stay (4.8 8.8 days) were all significantly less in laparoscopic sigmoid colectomy patients. The mean operative time for laparoscopic sigmoid colectomy was 212 minutes as compared with 143 minutes for open sigmoid colectomy ( < 0.05). Conversion rate of laparoscopic sigmoid colectomy to open procedure was 19.7 percent. All laparoscopic sigmoid colectomy patients received a lighted ureteral stent preoperatively, which was removed at the end of surgery. Relevant complications for laparoscopic sigmoid colectomy open sigmoid colectomy were as follows: anastomotic leak in 1 3 (1.5 3.4 percent) patients, hematuria in 64 6 (97 6.8 percent) patients, with an average duration for 2.93 3 days, urinary tract infection in 5 4 (7.6 4.5 percent) patients, and ureteral injury in 1 2 (1.5 2.2 percent) patients. Although the mean operating room charges were greater in the laparoscopic sigmoid colectomy patients ($9,566 $7,306) the mean hospital charges ($13,953 $14,863) were less.

CONCLUSIONS

We recommend laparoscopic sigmoid colectomy as the modality of treatment for diverticular disease. Laparoscopic sigmoid colectomy seems to be a reliable, safe and efficacious treatment modality with better outcomes for diverticular disease of the sigmoid colon. The operative time for laparoscopic sigmoid colectomy is decreasing as surgeons gain more experience.

Elective laparoscopic colonic resection for diverticular disease: results of a multicenter study in 179 patients

BACKGROUND

We undertook a retrospective multicenter study of elective laparoscopic sigmoidectomy for diverticulitis in order to assess the safety and the results of the procedure performed by a large number of surgeons.

MATERIALS AND METHODS

Between January 1998 and April 1999, the French Society of Laparoscopic Surgery recruited retrospectively 179 patients from 10 surgical units, operated on for elective laparoscopic sigmoidectomy. There were 94 men and 85 women with a mean age of 58 years (range, 30-82). The indications for surgery were acute attacks in 123 cases, complicated diverticulitis in 47 cases, and miscellaneous in 9 cases.

RESULTS

The performed procedure was a successful laparoscopic assisted sigmoidectomy in 154 cases (with totally intracorporeal anastomosis in 136 cases and hand-sewn anastomosis via small incision in 18 cases). The mean operation time was 223 min +/- 79 (range, 100-480). There was no mortality and 23 complications occurred in 23 patients (14.9%). Postoperative ileus lasted 2.5 +/- 0.9 days (range, 1-6), and oral intake started after 3.3 +/- 1.3 days (range, 1-12). The mean postoperative stay was 9.3 days (range, 4-50). Conversion to laparotomy was necessary in 25 cases (13.9%). The essential causes of conversion were obesity, severe adhesions, and colonic inflammation. The mean postoperative stay for the 25 converted patients was 13 +/- 8.5 days (range, 7-42).

CONCLUSION

Elective laparoscopic sigmoidectomy for diverticulitis is feasible and is safe. The complication and mortality rates are similar to those observed after open procedures. For experienced surgical teams, laparoscopic colonic resection is a good approach for selected patients suffering from symptomatic diverticulitis.

Laparoscopic colonic resection

BACKGROUND AND PURPOSE

In the last decade, laparoscopy has dramatically changed colonic surgery. Laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention on the laparoscopic oncologic operative technique, we compared the perioperative results and the long-term outcome of laparoscopic surgery (LS) with those of conventional open surgery (OS) in a series of 360 unselected consecutive patients.

PATIENTS AND METHODS

Between 1992 and 2001, excluding 102 patients with rectal tumors, 207 patients underwent laparoscopic colonic resection (72.5% for malignant lesions), whereas 153 (71.9% with malignant lesions) were treated by OS. The treatment modality was selected by the patients after reading the informed consent form. The statistical significance of differences in the morbidity and mortality rates, local recurrence rate, and incidence of distant metastases in the two groups was assessed by chi2 test. The survival probability analysis was performed by the Kaplan-Meier method. Significant differences in survival probability between groups were assessed by the log-rank test. A level of 5% was used as the criterion of statistical significance.

RESULTS

Laparoscopic surgery was technically feasible in 95.7% of the patients. No statistically significant difference was observed in the major complication rate (3.5% after LS and 3.3% after OS; P = 0.870) or in perioperative mortality (1.5% v 1.3%; P = 0.769). The mean follow-up in the patients with malignant disease was 42.2 months, during which time, we observed 2 cases of abdominal wall metastases (1.9%) in patients with advanced disease. The local recurrence rate was lower after LS than OS: 2.8% v 8.1%; P = 0.223). Distant metastases occurred in 8.6% of patients after LS and 9.3% after OS (P = 0.926). At 48 months of follow-up, the cumulative survival probability in the LS-completed malignant group was 0.934 compared with 0.860 after OS (P = 0.781).

CONCLUSION

Laparoscopic colonic resection for both benign and malignant lesions is technically feasible, without additional risks for the patients. However, oncologic outcomes have not been determined because no data from the ongoing randomized controlled trials are yet available.

Treating benign colon disorders using laparoscopic colectomy

Laparoscopic bowel surgery is a recent application of minimally invasive videoscopic techniques. Understanding the anatomy and physiology of the bowel, the background of bowel disorders and their treatment, signs and symptoms of bowel disease, and the patient selection process can help perioperative nurses better care for patients diagnosed with colon polyps, diverticulitis, and inflammatory bowel disease.

A Case-Control Study of Laparoscopic versus Open Sigmoid Colectomy for Diverticulitis

Laparoscopic sigmoid colectomy (LSC) for diverticular disease accounts for a limited number of laparoscopic colon cases performed nationally because of the technical challenge it presents. Our objective was to determine the feasibility and impact of the laparoscopic approach in elective sigmoid colectomy for diverticular disease and to compare these results with those of the open approach. Twenty elective laparoscopic sigmoid colectomies (LSCs) were performed for diverticulitis between April 1992 and July 1999 at a university-affiliated urban hospital. A case-control study was performed comparing LCS with a matched control group of conventional open sigmoidectomies. Fourteen of 20 sigmoidectomies were successfully completed laparoscopically. The mean operative time for LSC was similar to that for open sigmoid colectomy (251 vs 243 minutes). There was earlier return to oral intake in the LSC group (1 vs 5 days; P < 0.001). The mean length of stay was significantly shorter ( P = 0.029) in LSC (4.8 days) versus open sigmoid colectomy (7.8 days). Conversion to open sigmoidectomy extended hospital stay to 8.16 days. The overall complication rate was 10 per cent in both groups. We conclude that LSC can be performed effectively and with a low complication rate for diverticular disease. LSC provides the benefit of quicker return of bowel function and shorter hospitalization.