Hans J. Duepree

Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? ☆: Laparoscopy versus laparotomy

BACKGROUND Laparotomy for bowel resection is causally related to the development of small bowel obstruction (SBO) and ventral hernia, with incidences approaching 12% to 15% each. This report attempts to define the incidence of these access-related complications in a large group of patients undergoing laparoscopic-assisted bowel resection (LABR) and open bowel operation (OPEN). STUDY DESIGN A retrospective cohort of 716 consecutive patients undergoing either LABR (n = 211) or OPEN (n = 505) procedures between January 1995 and July 2000 was identified and selected from a prospective registry. RESULTS Index LABR (n = 211) and OPEN (n = 505) cases included segmental colectomy in 146 LABR and 408 OPEN patients; subtotal colectomy with or without stoma in 18 LABR and 6 OPEN patients; ileocolectomy in 37 LABR and 85 OPEN patients; and small bowel resection in 10 LABR and 6 OPEN patients. The mean followup periods in the LABR and OPEN groups were 2.71 years and 2.42 years, respectively. The incidence of wound hernia was significantly higher in OPEN cases (n = 65) compared with LABR (n = 5) (p < 0.05). The incidence of surgical repair of ventral hernia was also significantly higher in the OPEN group (28) compared with LABR (4) (p < 0.05). Postoperative SBO requiring hospitalization with conservative management occurred significantly less frequently in LABR patients (n = 4) compared with OPEN patients (n = 31) (p = 0.016). The need for surgical release of SBO was similar between the OPEN and LABR groups (n = 4 versus n = 11). The overall reoperation rate for these two complications was two times higher in the OPEN group than in the LABR group (7.7% versus 3.8%). CONCLUSIONS The data demonstrate that laparoscopic access for bowel operation significantly reduces the incidence of ventral hernia and SBO rates compared with laparotomy. This reduces the need for readmission to the hospital and additional surgical procedures, providing a potential source of decreased morbidity. It should be considered as a means of cost savings associated with laparoscopic bowel operations.

Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: Similarities and differences

AbstractPURPOSE: Although laparoscopic colectomy has demonstrated a variety of advantages, it remains unclear whether the reductions in length of stay and faster return of bowel function will offset potential increases in cost caused by operating time and instrumentation. The purpose of this study was to compare the direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis. METHODS: We compared consecutive elective open and laparoscopic sigmoid colectomies (n = 71 and n = 61, respectively) performed from March 1, 1999, through December 31, 2000. Data collected included age, gender, body mass index, American Society of Anesthesia score, indication for surgery, morbidity, mortality, conversion (laparoscopic only), operating time, and length of hospital stay. Direct cost data were provided by Stanford’s integrated hospital cost management and decision software. Indirect costs and total costs were not addressed. Data were analyzed by Student’s t-test and chi-squared test where appropriate. Significance was set at P < 0.05. All data are presented as mean ± standard error of the mean. RESULTS: There were 132 elective sigmoid colectomies for diverticular disease (61 laparoscopic and 71 open procedures). There were no significant differences between the groups with respect to age, male/female ratio, or body mass index. Operating time was similar (109 ± 7 minutes for laparoscopic procedures vs. 101 ± 7 minutes for open procedures). The laparoscopic group had a significantly shorter length of stay (3.1 ± 0.2 vs. 6.8 ± 0.4 days), fewer pulmonary complications (1 (1.6 percent) vs. 4 (5.6 percent)) and fewer wound infections (0 vs. 5 (7 percent)). Conversion to open colectomy was required in 4 (6.6 percent) of 61 patients. Readmission occurred in three laparoscopic colectomy patients (4.9 percent) and four open colectomy patients (5.6 percent). There was one operative death in the laparoscopic group (1.6 percent) and no deaths in the open group. Total direct cost per case was significantly less for laparoscopic procedures (

Advantages of Laparoscopic Resection for Ileocecal Crohn’s Disease

3,458 ± 437) than for open colectomies (

Results of a standardized technique and postoperative care plan for laparoscopic sigmoid colectomy: a 30-month experience.

4321 ± 501; P < 0.05, Student’s t-test), and operating costs were not significantly different between the groups. CONCLUSION: The data demonstrate that laparoscopic colectomy is a cost-effective means of electively managing sigmoid diverticular disease. This operative approach may become very important in an era of increasing constraints on hospital occupancy rates and access to nursing services in many regions of the country.

Clinically based management of rectal prolapse.

AbstractPURPOSE: Elective laparoscopic-assisted resection of terminal ileal Crohn’s disease is slowly gaining acceptance as an alternative to conventional surgery, based on the advantages of earlier return of bowel function, reductions in length of stay, and smaller wounds in a population likely to require reoperation. There is limited documentation of the cost-effectiveness of this approach, particularly with the reported longer operating times. The purpose of this study was to compare laparoscopic and open resections for terminal ileal Crohn’s disease. METHODS: We compared contemporaneous cohorts of patients undergoing initial elective laparoscopic or open resection for ileocecal Crohn’s disease between June 1, 1999 and October 31, 2000 at a single institution. Operative approach was at the discretion of the surgeon. Data collected included age, gender, body mass index, American Society of Anesthesiologists score, indication for surgery, morbidity, mortality, conversion (laparoscopic-resection group only), operating-room time, length of hospital stay, direct cost per case, 30-day readmission, and return to work. All data are presented as medians and interquartile ranges. Data analysis was performed with the Mann-Whitney U test, Fisher’s exact test, and Student’s t-test where appropriate. Significance was set at P < 0.05. RESULTS: There were 45 evaluable patients (laparoscopic-resection group, 21; open-resection group, 24). One procedure was considered a conversion because of the 13-cm incision required to exteriorize the phlegmon (conversion rate, 4.8 percent). The median age (laparoscopic-resection group, 31 years; open-resection group, 39 years) and gender distributions (male/female: laparoscopic-resection group, 12/9; open-resection group, 9/15) were significantly different between the two groups. Resumption of oral intake (operating-room day vs. second postoperative day; P < 0.05) and resumption of intestinal function (2 vs. 4 days; P < 0.05) were significantly faster in the laparoscopic-resection patients. The median length of hospital stay was significantly shorter for the laparoscopic-resection patients (3 (2–3) vs. 5 (4–6) days; P < 0.05). The 30-day readmission rate in the laparoscopic-resection group was 9.6 percent (2/21), whereas none of the open-resection patients required rehospitalization. The overall complication rates were comparable for the laparoscopic-resection and open-resection patients (14.3 vs. 16.7 percent; P not significant), although there was one anastomotic leak and one intra-abdominal abscess in the laparoscopic-resection group, requiring readmission and reintervention (9.6 percent; P not significant). The direct cost per case was significantly lower for the laparoscopic-resection group (

Evaluation of POSSUM and P‐POSSUM scoring systems in assessing outcome after laparoscopic colectomy

2,547 vs.

Advantages of laparoscopic colectomy in older patients.

2,985; P < 0.05, Student’s t-test). CONCLUSION: The laparoscopic-assisted approach to ileocecal Crohn’s disease results in a shortened length of stay and seems economically advantageous to open surgery.

Epidural anesthesia-analgesia shortens length of stay after laparoscopic segmental colectomy for benign pathology.

AbstractINTRODUCTION: Laparoscopic sigmoid colectomy has been accepted slowly despite potential advantages because of the perceptions of a steep learning curve and increased operative times and costs. The purpose of this article is to review the outcome of a standardization of all the intraoperative and postoperative processes used in our department for the performance of laparoscopic sigmoid colectomy. METHODS: A consecutive series of patients requiring laparoscopic sigmoid colectomy from March 1999 through December 2001 at the Cleveland Clinic Foundation, Cleveland, Ohio, was analyzed. Patients requiring sigmoid or rectosigmoid resection for all colonic pathologies were included. Criteria for exclusion from an attempted laparoscopic sigmoid colectomy were body mass index >35 and prior major abdominal surgeries (exclusive of hysterectomy, cholecystectomy, or appendectomy). Data collected included age, gender, indication for surgery, American Society of Anesthesiology class, body mass index, operative duration, length of hospital stay, complications, mortality, and 30-day readmission. The operative steps for laparoscopic sigmoid colectomy were as follows: 1) open insertion of the umbilical port; 2) placement of three operating ports; 3) dissection/division of the vascular pedicle after identification of the left ureter; 4) mobilization of the sigmoid and descending colon; 5) rectal mobilization/division; 6) exteriorization of the specimen; and 7) circular stapled anastomosis. Instrumentation for the procedure was standardized. Conversion was performed when a sequential step could not be completed in a reasonable time frame. A standard perioperative care plan was used. RESULTS: From March 1999 through December 2001, the primary surgeon performed 207 sigmoid colectomies, including 181 (87.4 percent) attempted laparoscopic sigmoid colectomies and 22 (12.1 percent) conversions. Indications for the laparoscopic sigmoid colectomies were diverticular disease (115), colonic neoplasia (32), prolapse (14), endometriosis (10), and other (10). The male/female ratio was 85:96, and the mean body mass index was 27.3 ± 5.6. Mean operative time was 119 ± 35 minutes. Mean length of stay was 2.9 ± 1.2 days for completed cases and 6.4 ± 1.4 days for converted cases. Anastomotic leaks occurred in two patients (1.1 percent), one of whom died of multisystem organ failure, yielding an operative mortality of 0.6 percent. The overall complication rate was 6.6 percent, and the 30-day readmission rate was 8 percent. CONCLUSION: The results indicate that a structured approach to laparoscopic sigmoid colectomy provides the surgeon with objective measures of operative progress that limit unduly long operations without increasing conversion rates and that control resource utilization. This approach provides a potential guideline for teaching and mastering laparoscopic sigmoid colectomy, reducing the learning curve, and optimizing results.

Analysis of both NM23-h1 and NM23-H2 expression identifies "at-risk" patients with colorectal cancer.

Background: Laparoscopic repair of rectal prolapse offers the potential of lower recurrence rates for transabdominal repair coupled with the advantages of minimally invasive colorectal surgery. There have been no direct comparisons of the laparoscopic Wells procedure (LWP) and laparoscopic resection with rectopexy (LRR). This study is the first to make a direct comparison of outcomes from laparoscopic LRR and LWP repairs using a selected, symptom-based choice of operative procedure. Methods: Consecutive patients presenting with complete rectal prolapse were evaluated by clinical history of the degree of constipation, diarrhea, or incontinence. Patients with a history of constipation or normal bowel habits with normal continence underwent LRR, whereas those with diarrhea or anal incontinence underwent LWP. The collected data included age, gender, operative time, length of hospital stay (LOS), operative blood loss, complications, and postoperative symptoms of constipation or diarrhea. Continence was scored using the Cleveland Clinic scoring system. Results: Of the 24 patients, 11 underwent LRR and 13 had LWP. The patients in both groups were predominantly, female (LRR, 9/1; LWP, 10/2). The LRR patients were significantly younger (48.6 vs 63.9 years p <0.001). Both operative time and LOS were significantly longer in the RR group (operative time, 128.5 ± 80.6 min vs 69.9 ± 13.4 min; LOS, 3.6 ± 3.1 days vs 2.2 ± 1.03 days). All patients in the LRR group had constipation preoperative, and no patients were incontinent clinically. Preoperatively, 7 of the 13 patients in the LWP group had preoperative diarrhea, and 1 patient had clinical constipation. A five patients experienced clinical symptoms of fecal incontinence, manifested in different degrees. Postoperative complications occurred only in the LRR group (1 case of abdominal wall hematoma and 2 cases of prolonged ileus). During a mean follow-up period of 18.1 months, there were no recurrences; 10 of the 11 LRR patients had correction of constipation; and 4 of 5 of the incontinent LWP patients had improvement in their symptoms. Constipation developed in one LWP patient. Conclusions: Clinical assessment of preoperative bowel function and continence allows accurate selection of the appropriate laparoscopic technique for repair of rectal prolapse without the added expense of anal physiologic testing. Although LRR may be associated greater morbidity than LWP, both procedures offer good functional outcome, with short LOS and low recurrence rates.

Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement

The purpose of this study was to compare the actual and predicted risk‐adjusted morbidity and mortality after laparoscopic colectomy (LAC) calculated using both the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P‐POSSUM) scoring systems.