Joe K. M. Fan

Impact of laparoscopic colorectal resection on surgical site infection.

Objectives:This study aimed to identify the risk factors of surgical site infection (SSI) in elective colorectal resection and the strategy for prevention of SSI in modern era of colorectal surgery. Background:The practice of colorectal surgery has undergone remarkable evolution recently because of application of laparoscopic resection. This could affect SSI in colorectal patients. An updated investigation of SSI under current practice of colorectal surgery would provide valuable information. Methods:This was a prospective study of SSI on 1011 patients, who had elective colorectal resection in a university teaching hospital, during January 2002 to December 2006. Standard definition and postoperation follow-up of SSI were adopted through collaboration between surgeons and wound surveillance program of Infection Control Unit. Risk factors of SSI were evaluated. Logistic regression was used to perform multivariate analysis and decide independent risk factors of SSI. Results:The overall rate of incisional SSI and organ/space SSI was 4.8% and 1.7%, respectively. Rate of incisional SSI in open and laparoscopic colorectal resection was 5.7% and 2.7%, respectively. Anastomotic leakage was the only factor that predicted organ/space SSI (P < 0.01). Independent risk factors of incisional SSI included blood transfusion [P = 0.047; odds ratio (OR) = 2.43; 95% confidence interval (CI): 1.0–5.9], anastomotic leakage (P < 0.01; OR = 6.5; 95% CI: 2.3–18.6), and open colorectal resection (P = 0.037; OR = 2.36; 95% CI: 1.1–5.3). Conclusion:In current practice of colorectal surgery, operative factors are more important than patient factors for SSI. Good surgical technique to reduce anastomotic leakage and reduce blood transfusion has paramount importance in SSI prevention. Laparoscopic surgery was associated with reduction of rate of SSI by more than 50% when compared with open surgery and would have a strong impact on the prevention of surgical infection.

Colorectal resection after stent insertion for obstructing cancer: comparison between open and laparoscopic approaches

Aim: To evaluate surgical outcomes after stent insertion for obstructing colorectal malignancy and to compare between laparoscopic and open approach. Methods: Surgical resection was performed after stent insertion for malignant colorectal obstruction in 36 patients with a median age of 73 years. Eighteen patients were treated with open resection, whereas 18 underwent a laparoscopic resection. The outcomes were evaluated and comparison was made between patients with laparoscopic and open resection. Results: The mean interval between stent insertion and surgery was 11 days. One patient died within 30 days (2.8%). The overall incidence of postoperative morbidity was 22% and reoperation was required in 3 patients (8.8%). The median postoperative hospital stay was 8.5 days for the open surgery group and 5.5 days for the laparoscopic group (P=0.004). The postoperative morbidity rates for the open and laparoscopic groups were 33.3% and 11.1%, respectively (P=0.228). In those patients with nonmetastatic disease, with the median follow-up of 20 months, the 5-year survival rate was 49.5%. Conclusions: Our experience showed that after successful endoscopic stent insertion for malignant colorectal obstruction, elective surgical resection could be performed safely. The combined endoscopic and laparoscopic procedure provides a less invasive alternative to the multistage open operations and is feasible for patients with obstructing colon cancer.

Transrectal intraperitoneal assess with transanal endoscopic operation (TEO) device in pig model

Background Gaining peritoneal access with subsequent safe closure is a prerequisite for natural orifice translumenal surgery (NOTES). We explored the possibility of transanal endoscopic operation (TEO) device to perform transrectal peritoneoscopy in a pig model. Objective Performing transrectal peritoneoscopy with TEO device in pig model. Methods Two pigs were used for transrectal peritoneoscopy. A 40-mm rectoscope was inserted via the anus after the induction of general anesthesia. Proctotomy was then created with diathermy and the endoscope was passed through the pararectal space into the peritoneal cavity. Proctotomy was closed with absorbable suture after completion of peritoneoscopy. Results Completion of the procedures was achieved in 2 pigs. Both pigs survived for more than 30 days. Necropsy revealed completely healed rectum with no evidence of leakage or abscess formation. Adhesions around the colostomy site were minimal. Conclusions In conclusion, incorporation of TEO system is safe and useful in animal model for creation and closure of proctotomy for natural orifice translumenal surgery in transrectal access, further experiment should be performed to validate the possibility of application in human. Potential complications need to be addressed and well documented.

A rare complication of laparoscopic low anterior resection.

We report a 70-year-old lady who suffered from carcinoma of rectum with the lowest border of the tumor at 5 cm from the anal verge. Preoperative staging did not show any distant metastasis. Laparoscopic low anterior resection with total mesorectal excision was performed. The rectum was transected with endoscopic stapler and a double stapling anastomosis with a circular stapler was attempted. The spear of the circular stapler pierced through the rectal stump and attempt to remove the spear by pulling the suture attached to the spear failed. A pair of strong laparoscopic forceps was used in an attempt to remove the spear. The spear broke during the attempt of removal. The stapler was withdrawn through the anus with a pair of laparoscopic forceps following it. A new circular stapler was used and the tip was tied to a suture and cotton tape. The pair of forceps, which was still at the anus, was used to pull the cotton tape and the suture through the original perforation at the rectal stump. The tip of the spear of the new stapler was guided through the original perforation of the rectal stump. Double stapling was then performed and the patient recovered uneventfully. This case showed that stapler complication in laparoscopic surgery could be salvaged without conversion.