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1.  Laparoscopic-assisted Colon Resections: Long-term Results and Survival 
Objective:
We reviewed the long-term results and patient survival for laparoscopic-assisted resection of colorectal malignancies. The place of laparoscopic colectomy for colorectal carcinomas is controversial. The techniques and expected surgical outcomes for patients undergoing laparoscopic and laparoscopic-assisted colectomies are being defined as these procedures become more acceptable and reach parity with, or even surpass, results of traditional operations. Anecdotal reports in the literature describe port-site and incisional tumor implantation in patients undergoing laparoscopic-assisted colectomies for colorectal malignancies. This raises concerns about whether these incisional tumor sites are more common in these patients and whether their survival is compromised by the laparoscopic technique.
Methods:
The authors reviewed data from 110 patients who underwent laparoscopic-assisted colectomies for colorectal cancer to determine the long-term results and survival and to compare the safety and efficacy of laparoscopic-assisted colectomy to the safety and efficacy of open colectomy. Between July 1991 and June 1999, 350 patients underwent laparoscopic-assisted colectomies. Of these, 110 patients had colorectal malignancies. Survival rates and patterns of recurrence were compared within the various TNM stages and compared with conventional data after open surgery. The American Joint Committee on Cancer staging for colorectal carcinomas and the Kaplan-Meier method were used to determine the survival curves.
Results:
Laparoscopic-assisted colon resections for colorectal malignancies were performed in 110 patients. Fifty-one percent of the patients were women, and 49% percent were men, with a mean age of 78.17 years. The mean follow-up was 43 months. Thirteen patients were converted to open operation due to various difficulties encountered during the procedure. Mean operative time was 128.16 minutes, and mean hospital stay was 6.91 days. Perioperative mortality was 2.77%. There were 4 local recurrences. The ten-year survival rates for the various stages were 78% for stage I, 33% for stage II, 30% for stage III, and 0% for stage IV. No port-site implantations occurred.
Conclusion:
Laparoscopic-assisted colon resection of colorectal carcinomas is technically feasible and safe. It allows earlier postoperative recovery and a shorter hospital stay. The long-term survival is also satisfactory. The incidence of port-site implants is no more than that with the conventional open technique. Determination of any benefits over the conventional open technique, however, still await prospective randomized trials.
PMCID: PMC3015573  PMID: 15984707
Laparoscopic colon resections; Laparoscopic-assisted colon resections; Colorectal malignancies
2.  Alvimopan Addition to a Standard Perioperative Recovery Pathway 
In this account, addition of alvimopan to a standard perioperative recovery pathway decreased length of stay and incidence of postoperative ileus for elective laparoscopic colectomy.
Background and Objectives:
Alvimopan, a peripherally acting mu-opioid receptor antagonist, decreased time to gastrointestinal recovery and hospital length of stay in open bowel resection patients in Phase 3 trials. However, the benefit in laparoscopic colectomy patients remains unclear.
Methods:
A retrospective case series review was performed to study addition of alvimopan to a well-established standard perioperative recovery pathway for elective laparoscopic colectomy. The main outcome measures were length of stay and incidence of charted postoperative ileus. Wilcoxon and chi-square tests were used to calculate P values for length of stay and postoperative ileus endpoints, respectively.
Results:
Demographic/baseline characteristics from the 101 alvimopan and 64 pre-alvimopan control patients were generally comparable. Mean length of stay in the alvimopan group was 1.55 days shorter (alvimopan, 2.81±0.95 days; control, 4.36±2.4 days; P<.0001). The proportion of patients with postoperative ileus was lower in the alvimopan group (alvimopan, 2%; control, 20%; P<.0001).
Conclusion:
In this case series, addition of alvimopan to a standard perioperative recovery pathway decreased length of stay and incidence of postoperative ileus for elective uncomplicated laparoscopic colectomy. The improvement in the mean length of stay for patients who receive alvimopan is a step forward in achieving a fast-track surgery model for elective laparoscopic colectomies.
doi:10.4293/108680811X13176785204076
PMCID: PMC3340958  PMID: 22643504
Alvimopan; Colectomy; Laparoscopic; Pathway
3.  Fast track multi-discipline treatment (FTMDT trial) versus conventional treatment in colorectal cancer--the design of a prospective randomized controlled study 
BMC Cancer  2011;11:494.
Background
Laparoscopy-assisted surgery, fast-track perioperative treatment are both increasingly used in colorectal cancer treatment, for their short-time benefits of enhanced recovery and short hospital stays. However, the benefits of the integration of the Laparoscopy-assisted surgery, fast-track perioperative treatment, and even with the Xelox chemotherapy, are still unknown. In this study, the three treatments integration is defined as "Fast Track Multi-Discipline Treatment Model" for colorectal cancer and this model extends the benefits to the whole treatment process of colorectal cancer. The main purpose of the study is to explore the feasibility of "Fast Track Multi-Discipline Treatment" model in treatment of colorectal cancer.
Methods
The trial is a prospective randomized controlled study with 2 × 2 balanced factorial design. Patients eligible for the study will be randomized to 4 groups: (I) Laparoscopic surgery with fast track perioperative treatment and Xelox chemotherapy; (II) Open surgery with fast track perioperative treatment and Xelox chemotherapy; (III) Laparoscopic surgery with conventional perioperative treatment and mFolfox6 chemotherapy; (IV) Open surgery with conventional perioperative treatment and mFolfox6 chemotherapy. The primary endpoint of this study is the hospital stays. The secondary endpoints are the quality of life, chemotherapy related adverse events, surgical complications and hospitalization costs. Totally, 340 patients will be enrolled with 85 patients in each group.
Conclusions
The study initiates a new treatment model "Fast Track Multi-Discipline Treatment" for colorectal cancer, and will provide feasibility evidence on the new model "Fast Track Multi-Discipline Treatment" for patients with colorectal cancer.
Trial registration
ClinicalTrials.gov: NCT01080547
doi:10.1186/1471-2407-11-494
PMCID: PMC3254142  PMID: 22111914
Colorectal surgery; Rehabilitation; Colorectal neoplasms; Hospitalization; Randomized controlled trial
4.  Laparoscopic versus open colectomy for colon cancer in an older population: a cohort study 
Background
Laparoscopic colectomy for colon cancer has been compared with open colectomy in randomized controlled trials, but these studies may not be generalizable because of strict enrollment and exclusion criteria which may explicitly or inadvertently exclude older individuals due to associated comorbidities. Previous studies of older patients undergoing laparoscopic colectomy have generally focused on short-term outcomes. The goals of this cohort study were to identify predictors of laparoscopic colectomy in an older population in the United States and to compare short-term and long-term outcomes.
Methods
Patients aged 65 years or older with incident colorectal cancer diagnosed 1996-2002 who underwent colectomy within 6 months of cancer diagnosis were identified from the linked Surveillance, Epidemiology, and End Results-Medicare database. Laparoscopic and open colectomy patients were compared with respect to length of stay, blood transfusion requirements, intensive care unit monitoring, complications, 30-day mortality, and long-term survival. We adjusted for potential selection bias in surgical approach with propensity score matching.
Results
Laparoscopic colectomy cases were associated with left-sided tumors; areas with higher population density, income, and education level; areas in the western United States; and National Cancer Institute-designated cancer centers. Laparoscopic colectomy cases had shorter length of stay and less intensive care unit monitoring. Although laparoscopic colectomy patients (n = 424) had fewer complications (21.5% versus 26.3%), lower 30-day mortality (3.3% versus 5.8%), and longer median survival (6.6 versus 4.8 years) compared with open colectomy patients (n = 27,012), after propensity score matching these differences disappeared.
Conclusions
In this older population, laparoscopic colectomy practice patterns were associated with factors which likely correlate with tertiary referral centers. Although short-term and long-term survival are comparable, laparoscopic colectomy offers shorter hospitalizations and less intensive care.
doi:10.1186/1477-7819-10-31
PMCID: PMC3296595  PMID: 22313593
5.  Laparoscopic Colon Resections With Discharge Less Than 24 Hours 
Laparoscopic colon surgery that incorporates multimodal perioperative care may allow patients to be discharged within the first 24 hours.
Background and Objectives:
A short hospital stay is one of the main advantages of laparoscopic surgery. Previous studies have shown that after a multimodal fast-track process, the hospital length of stay can be shortened to between 2 and 5 days. The objective of this review is to show that the hospital length of stay can, in some cases, be reduced to <24 hours.
Methods:
This study retrospectively reviews a surgeon's experience with laparoscopic surgery over a 12-month period. Seven patients were discharged home within 24 hours after minimally invasive laparoscopic surgical treatment, following a modified fast-track protocol that was adopted for perioperative care.
Results:
Of the 7 patients, 4 received laparoscopic right hemicolectomy for malignant disease and 3 underwent sigmoid colectomies for recurrent diverticulitis. The mean hospital stay was 21 hours, 47 minutes; the mean volume of intraoperative fluid (lactated Ringer) was 1850 mL; the mean surgical blood loss was only 74.3 mL; the mean duration of surgery was 118 minutes; and the patients were ambulated and fed a liquid diet after recovery from anesthesia. The reviewed patients had functional gastrointestinal tracts and were agreeable to the timing of discharge. On the follow-up visit, they showed no adverse consequences such as bleeding, infection, or anastomotic leak.
Conclusion:
Laparoscopic colon surgery that incorporated multimodal perioperative care allowed patients to be discharged within the first 24 hours. Careful postoperative outpatient follow-up is important in monitoring complications such as anastomotic leak, which may not present until postoperative day 5.
doi:10.4293/108680813X13654754535791
PMCID: PMC3771785  PMID: 23925012
Length of stay; Fast track; Laparoscopic colectomy
6.  Hand-assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis 
Surgical Endoscopy  2008;22(8):1769-1780.
Background
Evidence of benefits of laparoscopic and laparoscopic-assisted colectomies (LAC) over open procedures in gastrointestinal surgery has continued to accumulate. With its wide implementation, technical difficulties and limitations of LAC have become clear. Hand-assisted laparoscopic surgery (HALS) was introduced in an attempt to facilitate the transition from open techniques to minimally invasive procedures. Continuing debate exists about which approach is to be preferred, HALS or LAC. Several studies have compared these two techniques in colorectal surgery, but no single study provided evidence which procedure is superior. Therefore, a systematic review was carried out comparing HALS with LAC colorectal resection.
Methods
Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment, and data extraction were independently performed by two reviewers. Minimal outcome criteria for inclusion were operating time, conversion rate, hospital stay, and morbidity.
Results
Out of 468 studies a total of 13 studies were selected for comprehensive review. Two randomized controlled trials (RCT) and 11 non-RCTs, comprising 1017 patients, met the inclusion criteria. Because of possible clinical heterogeneity two groups of procedures were created: segmental colectomies and total (procto)colectomies. In the segmental colectomy group significant differences in favor of the HALS group were seen in operating time (WMD 19 min) and conversion rate (OR of 0.3 conversions). In the total (procto)colectomy group a significant difference in favor of the HALS group was seen in operating time (WMD 61 min).
Conclusions
This systematic review indicates that HALS provides a more efficient segmental colectomy regarding operating time and conversion rate, particularly accounting for diverticulitis. A significant operating time advantage exists for HALS total (procto)colectomy. HALS must therefore be considered a valuable addition to the laparoscopic armamentarium to avoid conversion and speed up complicated colectomies.
doi:10.1007/s00464-008-9857-4
PMCID: PMC2471396  PMID: 18437486
Systematic review; Meta-analysis; Colon; Colorectal; Intestinal surgery; Laparoscopy; Hand-assisted
7.  Overnight Hospital Stay After Colon Surgery for Adenocarcinoma 
A fast-track perioperative procedure may achieve the same low-risk, low-morbidity results for laparoscopic colectomy patients as seen with more conventional lengths of hospital stay.
A short hospital stay is one of the main advantages of the laparoscopic surgical technique. The process of developing and studying the “fast-track” process has contributed to a better understanding of the elements of perioperative care and has resulted in the reduction in length of stay (LOS) after colectomies. As we follow and refine this well-recognized multimodal approach, further decreases in the LOS can be expected. We present 2 octogenarian patients who, after receiving laparoscopic hemicolectomies for malignant disease, were discharged home <24 hours after their operations. Postoperative follow-ups did not show any adverse reaction to the early discharge. Modifying the multimodal perioperative technique with further refinement to the surgical technique appears to allow patients to be discharged home in the first 24 hours following laparoscopic colectomy.
doi:10.4293/108680812X13427982376789
PMCID: PMC3481244  PMID: 23477191
Length of stay; Colectomy; Multimodal rehabilitation; Fast-tracking
8.  Emergency Laparoscopic Colectomy: Does it Measure Up to Open? 
American journal of surgery  2009;197(3):296-301.
BACKGROUND
Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting.
METHODS
Using a prospectively collected database, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic operations were performed in 42 patients and were compared to 25 who were suitable for laparoscopy but received open colectomy.
RESULTS
The groups had similar demographics with no difference in age, gender or surgical indications. Blood loss was lower (118ml vs. 205ml, p <0.01) and postoperative stay shorter (8 vs. 11 days, p = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the two groups (1 vs. 3, p = 0.29).
CONCLUSIONS
With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open operation.
SUMMARY
Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. We demonstrate that increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open operation.
doi:10.1016/j.amjsurg.2008.09.010
PMCID: PMC2681486  PMID: 19245904
laparoscopic emergency colectomy; emergent colectomy; urgent colectomy laparoscopy; colectomy
9.  EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme 
BMC Cancer  2012;12:181.
Background
During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme, have been major changes in colorectal perioperative care. Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme. The EnROL trial (Enhanced Recovery Open versus Laparoscopic) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme.
Methods/design
EnROL is a phase III, multicentre, randomised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively, or until discharge if earlier. 202 patients will be recruited at approximately 12 UK hospitals and randomised using minimization at a central computer system in a 1:1 ratio. Recruiting surgeons will previously have performed >100 laparoscopic colorectal resections and >50 open total mesorectal excisions to minimize conversion. Eligible patients are those suitable for elective resection using either technique. Excluded patients include: those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely. The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 (MFI-20) with secondary outcomes including postoperative hospital stay; complications; reoperation and readmission; quality of life indicators; cosmetic assessments; standardized performance indicators; health economic analysis; the other four domains of the MFI-20. Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients.
Discussion
Should this trial demonstrate that laparoscopic surgery confers a significant clinical and/or health economic benefit this will further support the transition to this type of surgery, with implications for the training of surgeons and resource allocation.
Trial registration
ISRCTN48516968.
doi:10.1186/1471-2407-12-181
PMCID: PMC3441229  PMID: 22591460
Laparoscopy; Colon cancer; Rectal cancer; Enhanced recovery programme; Fast track surgery; Health economics; Cosmetic assessment; Fatigue; Randomised controlled trial; EnROL
10.  Laparoscopic surgery contributes more to nutritional and immunologic recovery than fast-track care in colorectal cancer 
Abstracts
Background
Many clinical trials had repeatedly shown that fast-track perioperative care and laparoscopic surgery are both preferred in the treatment of colorectal cancer. But few studies were designed to explore the diverse biochemical impacts of the two counterparts on human immunologic and nutritional status.
Methods
Ninety-two cases of colorectal cancer patients meeting the inclusion criteria were randomized to four groups: laparoscopy with fast-track treatment (LAFT); open surgery with fast-track treatment (OSFT); laparoscopy with conventional treatment (LAC); open surgery with conventional treatment (OSC). Peripheral blood tests including nutritional factors (albumin, prealbumin, and transferrin), humoral immunologic factors (IgG, IgM, and IgA), and cellular immunologic factors (T and NK cells) were evaluated. Blood samples were collected preoperatively (baseline) and 12 and 96 h after surgery (indicated as POH12 and POH96, respectively).
Results
Albumin, transferrin, prealbumin, and IgG levels were the highest in the LAFT group for both POH12 and POH96 time intervals. Repeated measures (two-way ANOVA) indicated that the difference of albumin, transferrin, and IgG level were attributed to surgery type (P < 0.05) and not perioperative treatment (P > 0.05). Only in the laparoscopy-included groups, the relative albumin and IgG levels of POH96 were obviously higher than that of POH12.
Conclusion
Laparoscopic surgery accelerated postoperative nutrition and immune levels rising again while fast-track treatment retarded the drop of postoperative nutrition and immune levels. Laparoscopic surgery might play a more important role than fast-track treatment in the earlier postoperative recovery of nutritional and immunologic status. Combined laparoscopic surgery with fast-track treatment provided best postoperative recovery of nutrition and immune status. These results should be further compared with the clinical outcomes of our FTMDT trial (clinicaltrials.gov: NCT01080547).
doi:10.1186/s12957-015-0445-5
PMCID: PMC4337197  PMID: 25649903
Colorectal surgery; Rehabilitation; Colorectal neoplasm; Fast-track care; Laparoscopy
11.  Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study 
Background
Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol.
Methods
The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed.
Results
Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission.
Conclusion
Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.
Highlights
•Benefits from laparoscopic colorectal surgery have been widely demonstrated.•A steep learning curve is considered the main limitation to its adoption.•We present short-term outcomes in a learning curve prospective series.•A modular, stepwise approach leads to excellent results.•Even trainees can safely learn both laparoscopic and open surgery, when strictly supervised.
doi:10.1016/j.amsu.2015.03.003
PMCID: PMC4388911  PMID: 25859386
Laparoscopic colorectal surgery; Laparoscopy; Learning curve; Colorectal cancer; Enhanced recovery programme
12.  Laparoscopic Versus an Open Colectomy in an Emergency Setting: A Case-Controlled Study 
Annals of Coloproctology  2013;29(1):12-16.
Purpose
Laparoscopy continues to be increasingly adopted for elective colorectal resections. However, its role in an emergency setting remains controversial. The aim of this study was to compare the outcomes between laparoscopic and open colectomies performed for emergency colorectal conditions.
Methods
A retrospective review of all patients who underwent emergency laparoscopic colectomies for various surgical conditions was performed. These patients were matched for age, gender, surgical diagnosis and type of surgery with patients who underwent emergency open colectomies.
Results
Twenty-three emergency laparoscopic colectomies were performed from April 2006 to October 2011 for patients with lower gastrointestinal tract bleeding (6), colonic obstruction (4) and colonic perforation (13). The hand-assisted laparoscopic technique was utilized in 15 cases (65.2%). There were 4 (17.4%) conversions to the open technique. The operative time was longer in the laparoscopic group (175 minutes vs. 145 minutes, P = 0.04), and the duration of hospitalization was shorter in the laparoscopic group (6 days vs. 7 days, P = 0.15). The overall postoperative morbidity rates were similar between the two groups (P = 0.93), with only 3 patients in each group requiring postoperative surgical intensive-care-unit stays or reoperations. There were no mortalities. The cost analysis did not demonstrate any significant differences in the procedural (P = 0.57) and the nonprocedural costs (P = 0.48) between the two groups.
Conclusion
Emergency laparoscopic colectomy in a carefully-selected patient group is safe. Although the operative times were longer, the postoperative outcomes were comparable to those of the open technique. The laparoscopic group did not incur a higher cost.
doi:10.3393/ac.2013.29.1.12
PMCID: PMC3624978  PMID: 23586009
Laparoscopy; Colectomy; Emergencies; Case-control studies
13.  Short Hospital Stay after Laparoscopic Colorectal Surgery without Fast Track 
Minimally Invasive Surgery  2012;2012:260273.
Purpose. Short hospital stay and equal or reduced complication rates have been demonstrated after fast track open colonic surgery. However, fast track principles of perioperative care can be difficult to implement and often require increased nursing staff because of more concentrated nursing tasks during the shorter hospital stay. Specific data on nursing requirements after laparoscopic surgery are lacking. The purpose of the study was to evaluate the effect of operative technique (open versus laparoscopic operation), but without changing nurse staffing or principles for peri- or postoperative care, that is, without implementing fast track principles, on length of stay after colorectal resection for cancer. Methods. Records of all patients operated for colorectal cancer from November 2004 to December 2008 in our department were reviewed. No specific patients were selected for laparoscopic repair, which was solely dependent on the presence of two specific surgeons at the same time. Thus, the patients were not selected for laparoscopic repair based on patient-related factors, but only on the simultaneous presence of two specific surgeons on the day of the operation. Results. Of a total of 540 included patients, 213 (39%) were operated by a laparoscopic approach. The median hospital stay for patients with a primary anastomosis was significantly shorter after laparoscopic than after conventional open surgery (5 versus 8 days, P < 0.001) while there was no difference in patients receiving a stoma (10 versus 10 days, ns), with no changes in the perioperative care regimens. Furthermore there were significant lower blood loss (50 versus 200 mL, P < 0.001) and lower complication rate (21% versus 32%, P = 0.006) in the laparoscopic group. Conclusion. Implementing laparoscopic colorectal surgery in our department resulted in shorter hospital stay without using fast track principles for peri- and postoperative care in patients not receiving a stoma during the operation. Consequently, we aimed to reduce hospitalisation without increasing cost in nursing staff per hospital bed. Length of stay was not reduced in patients receiving a stoma pointing at this group for specific intervention in the future. Furthermore, the complication rate was reduced in the laparoscopic group.
doi:10.1155/2012/260273
PMCID: PMC3506894  PMID: 23213498
14.  Position paper: management of perforated sigmoid diverticulitis 
Over the last three decades, emergency surgery for perforated sigmoid diverticulitis has evolved dramatically but remains controversial. Diverticulitis is categorized as uncomplicated (amenable to outpatient treatment) versus complicated (requiring hospitalization). Patients with complicated diverticulitis undergo computerized tomography (CT) scanning and the CT findings are used categorize the severity of disease. Treatment of stage I (phlegmon with or without small abscess) and stage II (phlegmon with large abscess) diverticulitis (which includes bowel rest, intravenous antibiotics and percutaneous drainage (PCD) of the larger abscesses) has not changed much over last two decades. On the other hand, treatment of stage III (purulent peritonitis) and stage IV (feculent peritonitis) diverticulitis has evolved dramatically and remains morbid. In the 1980s a two stage procedure (1st - segmental sigmoid resection with end colostomy and 2nd - colostomy closure after three to six months) was standard of care for most general surgeons. However, it was recognized that half of these patients never had their colostomy reversed and that colostomy closure was a morbid procedure. As a result starting in the 1990s colorectal surgical specialists increasing performed a one stage primary resection anastomosis (PRA) and demonstrated similar outcomes to the two stage procedure. In the mid 2000s, the colorectal surgeons promoted this as standard of care. But unfortunately despite advances in perioperative care and their excellent surgical skills, PRA for stage III/IV diverticulitis continued to have a high mortality (10-15%). The survivors require prolonged hospital stays and often do not fully recover. Recent case series indicate that a substantial portion of the patients who previously were subjected to emergency sigmoid colectomy can be successfully treated with less invasive nonoperative management with salvage PCD and/or laparoscopic lavage and drainage. These patients experience a surprisingly lower mortality and more rapid recovery. They are also spared the need for a colostomy and do not appear to benefit from a delayed elective sigmoid colectomy. While we await the final results ongoing prospective randomized clinical trials testing these less invasive alternatives, we have proposed (based primarily on case series and our expert opinions) what we believe safe and rationale management strategy.
doi:10.1186/1749-7922-8-55
PMCID: PMC3877957  PMID: 24369826
Complicated diverticulitis; Hartmann’s procedure; Primary resection anastomosis; Laparoscopic lavage and drainage; Percutaneous drainage
15.  A Technique for Laparoscopic-Assisted Colectomy Using Two Ports 
Objectives:
Laparoscopic colon and rectal surgery requires advanced laparoscopic skills. The aim of this study was to describe a novel technique for laparoscopic-assisted colectomy using only 2 ports and to review our initial experience with this technique for patients with benign colonic pathologies.
Methods:
A retrospective chart review of all patients who had laparoscopic-assisted colon surgery using this technique was performed. The technique is described.
Results:
For right colectomy, a 10-mm trocar for the camera was placed just below the umbilicus and a 5-mm working port just above the umbilicus. The colon was mobilized using one instrument and gravity assistance. The incisions were then connected, and the mobilized colon was pulled through this incision. For left-sided colectomy, the 5-mm working port was placed at the left suprapubic hairline, which was then extended for removal of the specimen. Sixty patients with benign colonic pathologies had laparoscopic-assisted colon surgery using only 2 ports. Conversion to open surgery was required in 4 cases. The average length of the skin incision was 3.82 cm, and the mean length of hospital stay was 4.18 days. Postoperative complications occurred in 11 patients (18%) and included anastomotic leak in 1 patient and wound infection in 2.
Conclusions:
Laparoscopic-assisted segmental colectomy using 2 ports is easy and feasible, with minimal skin incisions and fast recovery. Our initial experience suggests that it may be easier for the experienced colorectal surgeon to acquire the skills needed to perform this technique.
PMCID: PMC3016808  PMID: 15347112
Laparoscopy; colon; benign conditions; retrospective study
16.  Fast-track program in laparoscopic liver surgery: Theory or fact? 
AIM: To analyze our results after the introduction of a fast-track (FT) program after laparoscopic liver surgery in our Hepatobiliarypancreatic Unit.
METHODS: All patients (43) undergoing laparoscopic liver surgery between March 2004 and March 2010 were included and divided into two consecutive groups: Control group (CG) from March 2004 until December 2006 with traditional perioperative cares (17 patients) and fast-track group (FTG) from January 2007 until March 2010 with FT program cares (26 patients). Primary endpoint was the influence of the program on the postoperative stay, the amount of re-admissions, morbidity and mortality. Secondarily we considered duration of surgery, use of drains, conversion to open surgery, intensive cares needs and transfusion.
RESULTS: Both groups were homogeneous in age and sex. No differences in technique, time of surgery or conversion to open surgery were found, but more malignant diseases were operated in the FTG, and then transfusions were higher in FTG. Readmissions and morbidity were similar in both groups, without mortality. Postoperative stay was similar, with a median of 3 for CG vs 2.5 for FTG. However, the 80.8% of patients from FTG left the hospital within the first 3 d after surgery (58.8% for CG).
CONCLUSION: The introduction of a FT program after laparoscopic liver surgery improves the recovery of patients without increasing complications or re-admissions, which leads to a reduction of the stay and costs.
doi:10.4240/wjgs.v4.i11.246
PMCID: PMC3596505  PMID: 23493957
Liver surgery; Laparoscopy; Fast-track
17.  Laparoscopic vs. open approach for colorectal cancer: evolution over time of minimal invasive surgery 
BMC Surgery  2013;13(Suppl 2):S12.
Background
In the late '80s the successes of the laparoscopic surgery for gallbladder disease laid the foundations on the modern use of this surgical technique in a variety of diseases. In the last 20 years, laparoscopic colorectal surgery had become a popular treatment option for colorectal cancer patients.
Discussion
Many studies emphasized on the benefits stating the significant advantages of the laparoscopic approach compared with the open surgery of reduced blood loss, early return of intestinal motility, lower overall morbidity, and shorter duration of hospital stay, leading to a general agreement on laparoscopic surgery as an alternative to conventional open surgery for colon cancer. The reduced hospital stay may also decrease the cost of the laparoscopic surgery for colorectal cancer, despite th higher operative spending compared with open surgery. The average reduction in total direct costs is difficult to define due to the increasing cost over time, making challenging the comparisons between studies conducted during a time range of more than 10 years. However, despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients due to technical limitations or the characteristics of the patients that may affect short and long term outcomes.
Conclusions
The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology. Laparoscopic surgery for colon cancer demonstrates better short-term outcome, oncologic safety, and equivalent long-term outcome of open surgery. For rectal cancer, laparoscopic technique can be more complex depending on the tumor location. The advantages of minimally invasive surgery may translate better care quality for oncological patients and lead to increased cost saving through the introduction of active enhanced recovery programs which are likely cost-effective from the perspective of the hospital health-care providers.
doi:10.1186/1471-2482-13-S2-S12
PMCID: PMC3851244  PMID: 24267544
18.  Robotic-Assisted Versus Laparoscopic Colectomy: Cost and Clinical Outcomes 
Background and Objectives:
Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance.
Methods:
Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay.
Results:
Of 25 758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17 445 vs $15 448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001).
Conclusion:
Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies.
doi:10.4293/108680813X13753907291035
PMCID: PMC4035631  PMID: 24960484
Robotic assisted; Colectomy; Laparoscopic; Outcomes
19.  Fast-track program vs traditional care in surgery for gastric cancer 
AIM: To systematically review the evidence for the effectiveness of fast-track program vs traditional care in laparoscopic or open surgery for gastric cancer.
METHODS: PubMed, Embase and the Cochrane library databases were electronically searched for published studies between January 1995 and April 2013, and only randomized trials were included. The references of relevant studies were manually searched for further studies that may have been missed. Search terms included “gastric cancer”, “fast track” and “enhanced recovery”. Five outcome variables were considered most suitable for analysis: postoperative hospital stay, medical cost, duration to first flatus, C-reactive protein (CRP) level and complications. Postoperative hospital stay was calculated from the date of operation to the date of discharge. Fixed effects model was used for meta-analysis.
RESULTS: Compared with traditional care, fast-track program could significantly decrease the postoperative hospital stay [weighted mean difference (WMD) = -1.19, 95%CI: -1.79--0.60, P = 0.0001, fixed model], duration to first flatus (WMD = -6.82, 95%CI: -11.51--2.13, P = 0.004), medical costs (WMD = -2590, 95%CI: -4054--1126, P = 0.001), and the level of CRP (WMD = -17.78, 95%CI: -32.22--3.35, P = 0.0001) in laparoscopic surgery for gastric cancer. In open surgery for gastric cancer, fast-track program could also significantly decrease the postoperative hospital stay (WMD = -1.99, 95%CI: -2.09--1.89, P = 0.0001), duration to first flatus (WMD = -12.0, 95%CI: -18.89--5.11, P = 0.001), medical cost (WMD = -3674, 95%CI: -5025--2323, P = 0.0001), and the level of CRP (WMD = -27.34, 95%CI: -35.42--19.26, P = 0.0001). Furthermore, fast-track program did not significantly increase the incidence of complication (RR = 1.39, 95%CI: 0.77-2.51, P = 0.27, for laparoscopic surgery; and RR = 1.52, 95%CI: 0.90-2.56, P = 0.12, for open surgery).
CONCLUSION: Our overall results suggested that compared with traditional care, fast-track program could result in shorter postoperative hospital stay, less medical costs, and lower level of CRP, with no more complications occurring in both laparoscopic and open surgery for gastric cancer.
doi:10.3748/wjg.v20.i2.578
PMCID: PMC3923034  PMID: 24574728
Fast-track program; Traditional care; Gastric cancer; Meta-analysis; Laparoscopic and open surgery
20.  Laparoscopic Versus Open Colorectal Resection Within Fast Track Programs: An Update Meta-Analysis Based on Randomized Controlled Trials 
The objective of the study was to assess the safety and efficacy of laparoscopic colorectal surgery by comparing open operation within fast track (FT) programs. The Cochrane Library, PubMed, Embase and Chinese Biological Medicine Database were searched to identify all available randomized controlled trials (RCTs) comparing laparoscopic with open colorectal resection within FT programs. A total of seven RCTs were finally included, enrolling 714 patients with colorectal cancer: 373 patients underwent laparoscopic surgery and FT programs (laparoscopic/FT group) and 341 patients received open operation and FT programs (open/FT group). Postoperative hospital stay (weighted mean difference (WMD): 0.66; 95% CI: 0.27 - 1.04; P < 0.05), total hospital stay (WMD: 1.46; 95% CI: 0.40 - 2.51; P < 0.05) and overall complications (RR: 1.31; 95% CI: 1.12 - 1.54; P < 0.05) were significantly lower in laparoscopic/FT group than in open/FT group. However, no statistically significant differences on mortality (risk ratio (RR): 2.26; 95% CI: 0.62 - 8.22; P = 0.21), overall surgical complications (RR: 1.19; 95% CI: 0.94 - 1.51; P = 0.15) and readmission rates (RR: 1.33; 95% CI: 0.79 - 2.22; P = 0.28) were found between both groups. The laparoscopic colorectal surgery combined with FT programs shows high-level evidence on shortening postoperative and total hospital stay, reducing overall complications without compromising patients’ safety.
doi:10.14740/jocmr2177w
PMCID: PMC4471745  PMID: 26124904
Fast track programs; Enhanced recovery after surgery; Laparoscopic surgery; Colorectal surgery; Meta-analysis
21.  Fast-track surgery versus traditional perioperative care in laparoscopic colorectal cancer surgery: a meta-analysis 
BMC Cancer  2014;14:607.
Background
Both laparoscopic and fast-track surgery (FTS) have shown some advantages in colorectal surgery. However, the effectiveness of using both methods together is unclear. We performed this meta-analysis to compare the effects of FTS with those of traditional perioperative care in laparoscopic colorectal cancer surgery.
Methods
We searched the PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies until April 2014. The main end points were the duration of the postoperative hospital stay, time to first flatus after surgery, time of first bowel movement, total postoperative complication rate, readmission rate, and mortality.
Results
Five randomized controlled trials and 5 clinical controlled trials with 1,317 patients were eligible for analysis. The duration of the postoperative hospital stay (weighted mean difference [WMD], –1.64 days; 95% confidence interval [CI], –2.25 to –1.03; p < 0.001), time to first flatus (WMD, –0.40 day; 95% CI, –0.77 to –0.04; p = 0.03), time of first bowel movement (WMD, –0.98 day; 95% CI, –1.45 to –0.52; p < 0.001), and total postoperative complication rate (risk ratio [RR], 0.67; 95% CI, 0.56–0.80; p < 0.001) were significantly reduced in the FTS group. No significant differences were noted in the readmission rate (RR, 0.64; 95% CI, 0.41–1.01; p = 0.06) or mortality (RR, 1.55; 95% CI, 0.42–5.71; p = 0.51).
Conclusion
Among patients undergoing laparoscopic colorectal cancer surgery, FTS is associated with a significantly shorter postoperative hospital stay, more rapid postoperative recovery, and, notably, greater safety than is expected from traditional care.
doi:10.1186/1471-2407-14-607
PMCID: PMC4161840  PMID: 25148902
Fast track surgery; Laparoscopic surgery; Colorectal cancer
22.  Laparoscopic Sigmoid Colectomy for Chronic Diverticular Disease 
Background:
The feasibility of laparoscopic sigmoid colectomy for diverticular disease has now been well established. We report herein our experience with laparoscopic sigmoid colectomy in 100 patients who underwent laparoscopic colectomy for chronic diverticular disease.
Methods:
A retrospective review was performed of a 7-year period from January 1995 to June 2002. Chronic diverticular disease was treated with laparoscopic sigmoid colectomy in 100 patients. The setting was a community hospital. All cases were performed by 1 of 2 colorectal surgeons. All laparoscopic sigmoid colectomy patients received lighted ureteral stents placed preoperatively that were removed at the end of surgery.
Results:
Mean age was 61.6 years. The male to female ratio was 38:62. The mean estimated blood loss was 138 mL, liquid diet was tolerated for 2.4 days, and hospital length of stay was 4.6 days. The mean operative time for laparoscopic sigmoid colectomy was 196 minutes. Relative complications for laparoscopic sigmoid colectomy are as follows: anastomotic leak in 2 (3.0%) patients, hematuria in 95 (95%) with an average duration for 3.1 days, urinary tract infection in 6 (6%), and ureteral injury in 1 (1%). The mean operating room charges in the laparoscopic sigmoid colectomy patients was $9,643.
Conclusion:
We recommend laparoscopic sigmoid colectomy as the modality of treatment for chronic diverticular disease. Laparoscopic sigmoid colectomy appears to be a reliable, safe, and efficacious treatment modality for chronic diverticular disease. The operative time for laparoscopic sigmoid colectomy is decreasing as surgeons gain more experience.
PMCID: PMC3015646  PMID: 16381349
Laparoscopy; Colectomy; Diverticulitis; Sigmoid colon
23.  Management of postoperative ileus: focus on alvimopan 
Postoperative ileus (POI) is a transient loss of coordinated peristalsis precipitated by surgery and exacerbated by opioid pain medication. Ileus causes a variety of symptoms including bloating, pain, nausea, and vomiting, but particularly delays tolerance of oral diet and liquids. Thus POI is a primary determinant of hospital stay after surgery. ‘Fast-track’ recovery protocols, opioid sparing analgesia, and laparoscopic surgery reduce but do not eliminate postoperative ileus. Alvimopan is a mu opioid receptor antagonist that blocks the effects of opioids on the intestine, while not interfering with their centrally mediated analgesic effect. Several large randomized clinical trials have demonstrated that alvimopan accelerates the return of gastrointestinal function after surgery and subsequent hospital discharge by approximately 20 hours after elective open segmental colectomy. However, it has not been tested in patients undergoing laparoscopic surgery and is less effective in patients receiving nonsteroidal anti-inflammatory agents in a narcotic sparing postoperative pain control regimen. Safety concerns seen with chronic low dose administration of alvimopan for opioid bowel dysfunction have not been noted with its acute use for POI.
PMCID: PMC2621409  PMID: 19209278
alvimopan; postoperative ileus; gastrointestinal surgery
24.  Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer 
Purpose
Several multi-institutional prospective randomized trials have demonstrated short-term benefits using laparoscopy. Now the laparoscopic approach is accepted as an alternative to open surgery for colon cancer. However, in prior trials, the transverse colon was excluded. Therefore, it has not been determined whether laparoscopy can be used in the setting of transverse colon cancer. This study evaluated the peri-operative clinical outcomes and oncological quality by pathologic outcomes of laparoscopic surgery for transverse colon cancer.
Materials and methods
Analysis of the medical records of patients who underwent laparoscopic colorectal resection from August 2004 to November 2007 was made. Computed tomography, barium enema, and colonoscopy were performed to localize the tumor preoperatively. Extended right hemicolectomy, transverse colectomy, and extended left hemicolectomy were performed for transverse colon cancer. Surgical outcomes and pathologic outcomes were compared between transverse colon cancer (TCC) and other site colon cancer (OSCC).
Results
Of the 312 colorectal cancer patients, 94 patients underwent laparoscopic surgery for OSCC, and 34 patients underwent laparoscopic surgery for TCC. Patients with TCC were similar to patients with OSCC in age, gender, body mass index, operating time, blood loss, time to pass flatus, start of diet, hospital stay, tumor size, distal resection margin, proximal resection margin, number of lymph nodes, and radial margin. One case in TCC and three cases in OSCC were converted to open surgery.
Conclusions
Laparoscopic surgery for transverse colon cancer and OSCC had similar peri-operative clinical and acceptable pathological outcomes.
doi:10.1007/s00384-008-0471-7
PMCID: PMC2386750  PMID: 18379794
Laparoscopy; Transverse colon; Colon cancer
25.  Hospital-level outcomes associated with laparoscopic colectomy for cancer in the minimally invasive era 
Background
Compared to the open approach, randomized trials have shown that laparoscopic colectomy is associated with a shorter hospitalization without increases in morbidity or mortality rates. With broader adoption of laparoscopic colectomy for cancer in the United States, it is unclear if laparoscopic colectomy continues to be associated with shorter hospitalization and comparable morbidity.
Purpose
To determine if hospitals where a greater proportion of colon resections for cancer are approached laparoscopically (laparoscopy rate) achieve improved short-term outcomes compared to hospitals with lower laparoscopy rates.
Methods
From the 2008–2009 Nationwide Inpatient Sample, we identified hospitals where ≤12 colon resections for cancer where reported with ≥1 approached laparoscopically. We assessed the correlation between a hospital’s laparoscopy rate and risk-standardized outcomes (intra- and post-operative morbidity, in-hospital mortality rates, and average length of stay).
Results
Overall, 6,806 colon resections were performed at 276 hospitals. Variation was noted in hospital laparoscopy rates (median=52.0%, range=3.8–100%) and risk-standardized intra- (2.7%, 1.8–8.6%) and post-operative morbidity (27.8%, 16.4–53.4%), in-hospital mortality (0.7%, 0.3–42.0%), and average length of stay (7.0 days, 4.9–10.3 days). While no association was noted with in-hospital mortality, higher laparoscopy rates were correlated with lower post-operative morbidity (correlation coefficient [r]=−0.12, p=0.04) and shorter hospital stays (r=−0.23, p<0.001), but higher intra-operative morbidity (r=0.19, p<0.001) rates. This was not observed among hospitals with high procedure volumes.
Conclusions
Higher laparoscopy rates were associated with only slightly lower post-operative morbidity rates and modestly shorter hospitalizations.
doi:10.1007/s11605-012-2018-z
PMCID: PMC3670114  PMID: 22948842
Laparoscopic colectomy; surgical outcomes

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