Jimmy C. M. Li

Long-term morbidity and oncologic outcomes of laparoscopic-assisted anterior resection for upper rectal cancer: ten-year results of a prospective, randomized trial.

PURPOSE: We have previously reported the five-year results of a randomized trial comparing laparoscopic and open resection for cancer of the upper rectum and rectosigmoid junction. The aim of this follow-up study is to report on the long-term morbidity and ten-year oncologic outcomes among the subgroup of patients with upper rectal cancer. METHODS: From September 1993 to October 2002, 153 patients with upper rectal cancer were randomly assigned to receive either laparoscopic-assisted (n = 76) or open (n = 77) anterior resection. Patients were last followed up in December 2007. Long-term morbidity, survival, and disease-free interval were prospectively recorded. Data were analyzed by intention-to-treat principle. RESULTS: The demographic data of the two groups were comparable. More patients in the open group developed adhesion-related bowel obstruction requiring hospitalization (P = 0.001) and intervention. The overall long-term morbidity rate was also significantly higher in the open group (P = 0.012). After curative resection, the probabilities of cancer-specific survival at ten years of the laparoscopic-assisted and open groups were 83.5 percent and 78.0 percent, respectively (P = 0.595), and their probabilities of being disease-free at ten years were 82.9 percent and 80.4 percent, respectively (P = 0.698). CONCLUSION: Laparoscopic-assisted anterior resection for upper rectal cancer is associated with fewer long-term complications and similar ten-year oncologic outcomes when compared with open surgery.

Electroacupuncture Reduces Duration of Postoperative Ileus After Laparoscopic Surgery for Colorectal Cancer

BACKGROUND & AIMS We investigated the efficacy of electroacupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic surgery for colorectal cancer. METHODS We performed a prospective study of 165 patients undergoing elective laparoscopic surgery for colonic and upper rectal cancer, enrolled from October 2008 to October 2010. Patients were assigned randomly to groups that received electroacupuncture (n = 55) or sham acupuncture (n = 55), once daily from postoperative days 1-4, or no acupuncture (n = 55). The acupoints Zusanli, Sanyinjiao, Hegu, and Zhigou were used. The primary outcome was time to defecation. Secondary outcomes included postoperative analgesic requirement, time to ambulation, and length of hospital stay. RESULTS Patients who received electroacupuncture had a shorter time to defecation than patients who received no acupuncture (85.9 ± 36.1 vs 122.1 ± 53.5 h; P < .001) and length of hospital stay (6.5 ± 2.2 vs 8.5 ± 4.8 days; P = .007). Patients who received electroacupuncture also had a shorter time to defecation than patients who received sham acupuncture (85.9 ± 36.1 vs 107.5 ± 46.2 h; P = .007). Electroacupuncture was more effective than no or sham acupuncture in reducing postoperative analgesic requirement and time to ambulation. In multiple linear regression analysis, an absence of complications and electroacupuncture were associated with a shorter duration of postoperative ileus and hospital stay after the surgery. CONCLUSIONS In a clinical trial, electroacupuncture reduced the duration of postoperative ileus, time to ambulation, and postoperative analgesic requirement, compared with no or sham acupuncture, after laparoscopic surgery for colorectal cancer. ClinicalTrials.gov number, NCT00464425.

Long-term oncologic outcomes of laparoscopic versus open surgery for rectal cancer: a pooled analysis of 3 randomized controlled trials.

Objective:To compare long-term oncologic outcomes between laparoscopic and open surgery for rectal cancer and to identify independent predictors of survival. Background:Few randomized trials comparing laparoscopic and open surgery for rectal cancer have reported long-term survival data. Methods:Data from the 3 randomized controlled trials comparing curative laparoscopic (n = 136) and open surgery (n = 142) for upper, mid, and low rectal cancer conducted at the Prince of Wales Hospital, Hong Kong, between September 1993 and August 2007 were pooled together for this analysis. Survival and disease status were updated to February 2012. Survival was calculated using the Kaplan-Meier method, and independent predictors of survival were determined using the Cox regression analysis. Results:The demographic data of the 2 groups were comparable. The median follow-up time of living patients was 124.5 months in the laparoscopic group and 136.6 months in the open group. At 10 years, there were no significant differences in locoregional recurrence (5.5% vs. 9.3%; P = 0.296), cancer-specific survival (82.5% vs. 77.6%; P = 0.443), and overall survival (63.0% vs. 61.1%; P = 0.505) between the laparoscopic and open groups. There was a trend toward lower recurrence rate at 10 years in the laparoscopic group than in the open group among patients with stage III cancer (P = 0.078). The Cox regression analysis showed that stage III cancer, lymphovascular permeation, and blood transfusion, but not the operative approach, were independent predictors of poorer cancer-specific survival. Conclusions:This pooled analysis with a follow-up of more than 10 years confirms the long-term oncologic safety of laparoscopic surgery for rectal cancer.

In vitro porcine training model for colonic endoscopic submucosal dissection: an inexpensive and safe way to acquire a complex endoscopic technique

BackgroundColonic endoscopic submucosal dissection (ESD) has developed in recent years to permit en bloc resection of larger colorectal lesions that cannot be done by standard polypectomy or mucosal resection techniques. Colonic ESD is technically demanding and has a steep learning curve. Adequate training is essential to make ESD a reliable treatment for colorectal neoplasms. We aim to share our early experience with an in vitro porcine training model for colonic ESD.MethodResected porcine distal colon was used to set up a training model for ESD, which was performed as in human using a standard endoscope and dissecting devices. Size of the lesions, operation time, en bloc resection rate, and perforation rate were recorded.ResultsTen consecutive colonic ESD procedures were performed by a single endoscopist. Incomplete resection and perforation were encountered during the first two procedures. No perforation occurred in subsequent procedures and the operation time per task also decreased gradually. The setup cost for this model was only around US

Chinese validation of Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire

30.ConclusionsThe in vitro porcine model is easy and inexpensive to set up. Our initial experience showed that the model could simulate colonic ESD in human and technical proficiency improved by repetition. This simple setup may be a promising training model for endoscopists working in areas with a low incidence of early gastric cancer.

Institution learning curve of laparoscopic colectomy—a multi-dimensional analysis

Introduction and hypothesisThe purpose of this study was to investigate the reliability and validity of the Chinese version of Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ).MethodsWomen who presented for pelvic floor disorders completed the Chinese version of PFDI and PFIQ, SF-36, a 3-day urinary and fecal diary. POP-Q assessment, urodynamic study, anal manometry, and ultrasound were performed where appropriate.ResultsFive hundred and ninety-seven women completed the study. The Cronbach’s alpha and test–retest reliability of PFDI and PFIQ was 0.92 and 0.98, and 0.77 and 0.79, respectively. Convergent validity was demonstrated with negative correlation of PFDI and PFIQ with SF-36; positive correlation of staging of prolapse, urinary or fecal incontinent episodes with the respective subscales of PFDI and PFIQ.ConclusionsThe Chinese version of PFDI and PFIQ are reliable and valid condition-specific health-related quality of life questionnaires for women with pelvic floor disorders.

Emergency Laparoscopic-Assisted Versus Open Right Hemicolectomy for Complicated Cecal Diverticulitis: A Comparative Study

BackgroundThis study aimed to evaluate the learning curve for laparoscopic colorectal resection of a university colorectal unit, the operative outcome in its developing and established period of laparoscopic colorectal resection is compared.MethodsWe analyzed 1,031 consecutive patients who underwent laparoscopic colorectal resections for colorectal carcinoma performed in a colorectal unit between April 1992 and December 2008. Multi-dimensional analyses of the learning curves of the institution and seven individual surgeons were performed.ResultsThe operative outcomes of period 2 (2002–2008) was generally better than period 1 (1992–2001), in terms of operative time, number of lymph nodes retrieved, intra-operative blood loss and transfusion. The conversion rate of period 1 was higher than period 2 (19.7% vs. 5.1%, p < 0.001). There were no difference in the rates of intra-operative complications (2% vs. 3.3%, p = 0.32) and major post-operative complications (6% vs. 4.5%, p = 0.28). Analysis of the operative time using moving average method showed that the operative time of period 2 was generally shorter than that of period 1. The operative time transiently increased when there were new trainee surgeons joining the program. The CUSUM analysis of institutional conversion rate showed a steady state being reached at 310 cases. For the rates of intra-operative and major post-operative complications, steady states were both achieved at around 50 cases, and these rates were maintained during the whole study period.ConclusionsOperative outcome of laparoscopic colorectal resection improved with experience. Continuous training of new trainee would not affect the operative outcomes of an established specialized unit.

Laparoscopic total colectomy for colorectal cancers: a comparative study.

BACKGROUND Emergency open colectomy is generally agreed, by most surgeons, to be the treatment of choice for complicated cecal diverticulitis. However, the literature on the use of laparoscopy in treating this surgical emergency is scanty. This study aimed to evaluate the feasibility and safety of emergency laparoscopic-assisted right hemicolectomy for complicated cecal diverticulitis and to compare its operative and short-term clinical outcomes with the open approach. PATIENTS AND METHODS Between September 2001 and June 2006, 18 consecutive patients with an intraoperative diagnosis of complicated cecal diverticulitis underwent emergency right hemicolectomy at our institution, 6 with the laparoscopic-assisted approach and 12 with the open approach. Clinical data were retrospectively collected and compared between the two groups. RESULTS The demographic data of the two groups were comparable. The operative time was similar between the two groups, but the laparoscopic-assisted group had significantly less blood loss (35 vs. 100 mL; P = 0.041). Although the time to first bowel motion was significantly shorter in the laparoscopic-assisted group (3.5 vs. 5 days; P = 0.041), the time to full ambulation and the duration of hospital stay were not different between the two groups. More patients in the open group developed postoperative complications (50 vs. 33.3%), but the difference was not statistically significant. CONCLUSIONS With the availability of experienced laparoscopic surgeons, emergency laparoscopic-assisted right hemicolectomy can be safely performed in patients with complicated cecal diverticulitis. Compared with the open approach, the laparoscopic-assisted approach is associated with less blood loss and earlier return of bowel function.

Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms.

BackgroundNo previous report could be found in the literature comparing laparoscopic and open total colectomy for colorectal cancers, especially synchronous colorectal cancers. This study aimed to compare the short-term clinical outcomes and oncologic results of laparoscopic and open total colectomy or proctocolectomy for colorectal cancers.MethodsBetween July 1997 and January 2005, six patients with colorectal cancers underwent elective laparoscopic total colectomy or proctocolectomy at the authors’ institution. Clinical data for 12 patients who underwent elective open total colectomy or proctocolectomy for colorectal cancers during the same period were prospectively collected and compared.ResultsThe median follow-up periods were 43.9 months for the laparoscopic group and 48.2 months for the open group. Conversion to open procedure was required for one patient (16.7%) in the laparoscopic group because of bleeding. The median operative time was significantly longer in the laparoscopic group (427.5 min; range, 280–480 min vs 172.5 min; range, 90–260 min; p = 0.001). The patients in the laparoscopic group required a significantly shorter duration of parenteral analgesia (3 vs 5 days; p = 0.01), but there were no differences in time to first bowel motion, time to resumption of diet, time to full ambulation, and duration of hospital stay between the two groups. Perioperative morbidity rates were comparable between the two groups, and there was no operative mortality. The oncologic results, including number of lymph nodes removed, recurrence rates, and survival rates, were similar in the two groups.ConclusionsLaparoscopic total colectomy has short-term clinical outcomes (postoperative recovery and perioperative morbidity and mortality rates) and oncologic results similar to those of open surgery for treating patients with colorectal cancers. Our study has shown that the only advantage of laparoscopic over open surgery is a shorter duration of analgesic requirement, but at the expense of a longer operative time.

Small-bowel Intestinal Obstruction Caused by an Unusual Internal Hernia

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.