ORIGINAL CONTRIBUTION
Obesity Increases the Risk of Postoperative Peripheral Neuropathy After Minimally Invasive Colon and Rectal Surgery Vamsi R. Velchuru, F.R.C.S.(Edinb.), F.R.C.S.(Gen. Surg.)1 Bastian Domajnko, M.D. 2 • Ashwin deSouza, M.D.1 • Slawomir Marecik, M.D.1 Leela M. Prasad, M.D., M.S., F.R.C.S.(Edinb.), F.R.C.S.(C.)1 • John J. Park, M.D.1 Herand Abcarian, M.D.3,4 1 Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois 2 Rochester Colon & Rectal Surgeons, P.C., Rochester, New York 3 Division of Colon and Rectal Surgery, University of Illinois at Chicago Medical Center, Chicago, Illinois 4 Division of Colon and Rectal Surgery, John H Stroger Hospital of Cook County, Chicago, Illinois
BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively
maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. Financial Disclosure: None reported. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Tripartite Meeting (Early Results), Boston, MA, June 7 to 11, 2008. Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: Vamsi R. Velchuru, F.R.C.S.(Edinb.), F.R.C.S.(Gen. Surg.), James Paget University Hospitals, Lowestoft Road, Great Yarmouth, United Kingdom NR31 6LA. E-mail: [email protected] Dis Colon Rectum 2014; 57: 187–193 DOI: 10.1097/DCR.0000000000000037 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 2 (2014)
PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twentythree patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk
187
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ostoperative peripheral nerve injury is an uncommon but potentially significant complication of major surgery. The incidence of postoperative nerve injury ranges from 1 in 50 to 1 in 1000 patients undergoing general anesthesia1–3; however, the exact incidence is unknown. The etiology of postoperative neuropathy is multifactorial, although most cases are thought to be attributed to patient positioning, stretching, or compression of nerves and inadequate protection of susceptible sites. Abdominal wall retractors have also been implicated in causing nerve injuries.4–6 The majority of cases described are ulnar nerve injuries; however, there are reports describing injuries involving the brachial plexus, radial, femoral, sciatic, and common peroneal nerves.1–7 Femoral neuropathy has been well described in patients who have undergone abdominal operations, in particular those undergoing pelvic surgery requiring the use of Pfannenstiel incisions8 and abdominal wall retractors. Clinical features of postoperative nerve injury range from a mild self-limiting sensory disturbance to a profound and disabling sensorimotor deficit and can be a medicolegal issue.9,10 Major laparoscopic surgery requires unique positioning and steep tilt of the patient with longer operating times, resulting in a potential increase in the incidence of peripheral nerve injury compared with open operations. To date, no large studies exist that examined the prevalence of postoperative neuropathy after minimally invasive colon and rectal surgery (MIS). The objective of the study was to compare the incidence of postoperative peripheral neuropathy in minimally invasive versus open colon and rectal operations. Our goal was to review the outcomes after postoperative neuropathy and to identify risk factors for nerve injury.
robotic surgeries. All of the operations were performed by 1 of 3 board-certified colon and rectal surgeons in a community-based teaching hospital. Operations included colon and rectal resections for both benign and malignant disease. Demographics, operative details, and in-hospital and follow-up data were extracted from hospital medical and office charts. Postoperative neuropathy was defined as any symptom or sign of nerve injury (eg, anesthesia, paresthesia, hyperesthesia, pain, or paresis in a specific nerve distribution) occurring at any time after surgery, starting immediately in the postoperative period. Potential risk factors for nerve injury were also evaluated. These included sex, age, BMI, presence of diabetes mellitus or arthritis, patient positioning (lithotomy vs supine), incision type for specimen extraction (Pfannenstiel vs midline), and operative time. A standard technique of patient positioning was used throughout the study period. Operations were performed either in the supine position (for right hemicolectomy or stoma formation) or in modified lithotomy (for left colectomy, sigmoid resection, low anterior resection, and total colectomy). Securing of the patient was always undertaken by the operating surgeon. All of the laparoscopic and robotic operations involved the use of a bean bag with the arms tucked at the sides. Both arms were well padded, especially at bony prominence of the elbows and wrist. These help in protecting the nerves against the hardened bean bag during steep positioning. Padded shoulder supports were used to prevent the patient from sliding down the table. Patients were firmly secured at the chest to the table with tape. Padded Allen stirrups were used for patients in the modified lithotomy position, and care was taken to minimize pressure on the peroneal nerve. Pfannenstiel incisions were used for specimen extraction or hand-port placement in the majority of MIS cases. Midline incisions were used for open procedures. Approval for this study was granted by the institutional review board of Advocate Lutheran General Hospital. Statistical analysis was performed using SPSS version 19 (IBM SPSS Statistics, Chicago, IL). χ2 and Fisher exact test were used for categorical data. Continuous data were analyzed with the Student t test or the Mann-Whitney U test. Forward stepwise logistic regression was used for multivariate analysis. A p < 0.05 was considered statistically significant.
METHODS
RESULTS
A retrospective review of a prospectively maintained single-institution database of consecutive patients undergoing minimally invasive and open colon and rectal operations between March 2004 and April 2011 was performed. Patient complications, including postoperative neuropathy, were gathered in a prospective database. MIS included laparoscopic, hand-assisted laparoscopic, and
A total of 1514 abdominal colorectal operations were performed over a 7-year period. Of those, 1111 procedures (73.4%) were minimally invasive; these included laparoscopic (n = 479), hand-assisted laparoscopic (n = 466), and robotic (n = 166) operations. A total of 403 cases (26.6%) were performed as open surgery. The number of MIS cases increased each year, a statistically significant finding
of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures. KEY WORDS: Laparoscopic surgery; Neuropathy; Robotic
surgery.
P
189
Diseases of the Colon & Rectum Volume 57: 2 (2014)
Table 1. Procedures performed Laparoscopic (n = 945) Right colectomy Left colectomy/sigmoid colectomy Low anterior resection/APR/rectopexy IPAA/total/subtotal colectomy Small bowel resection Colostomy/ileostomy formation Colostomy/ileostomy reversal Othera
Robotic (n = 166)
301 22 453 87 12 53 0 17
50 3 107 6 0 0 0 0
Open (n = 403) 40 16 69 28 32 10 152 56
APR = abdominoperineal resection. a Other includes adhesiolysis, ventral hernia repairs, diagnostic procedures, and other partial colectomy.
(linear-by-linear association, p = 0.002). Table 1 lists the type of operations performed with each technique. Twenty-three of 1514 patients (1.5%) developed peripheral neuropathy in the postoperative period (Table 2). Table 3 illustrates the types of neuropathy and the outcomes. All but 1 case occurred in patients undergoing laparoscopic or robotic surgery. The mean patients age was 56 years (range, 46–84 years). Most of the neuropathy occurred in the upper extremities (n = 16). Sixteen cases were right-sided injuries, 5 were left sided, and 2 patients had bilateral injuries. Nerves injured included the median, radial, ulnar, femoral, lateral femoral cutaneous, and genitofemoral nerves (Table 3). Two patients had a brachial plexus neuropathy and 3 patients had 2 different nerve injuries simultaneously. Bilateral common peroneal nerve injuries were noted in the patient who had open surgery. In all of the cases, symptoms of nerve injury were sensory (eg, anesthesia, paresthesias, or hyperesthesia). One patient had concurrent motor deficit. Symptoms developed in the immediate postoperative period. Symptoms resolved preceding discharge in 7 patients, within 4 weeks of discharge in 10 patients, within 5 months in 4 patients, and within a year for the remaining 2 patients. None of the patients had a significant disabling neuropathy that affected quality of life. Demographics and outcomes were compared between the MIS group and the open group (Table 4). Patients undergoing laparoscopic or robotic surgery had a significantly higher incidence of postoperative neuropathy compared with patients undergoing open surgery (p = 0.015). There were also statistically significant differences in the incidence of diabetes mellitus, age, operative time, patient positioning (lithotomy), BMI, and the use of a Pfannenstiel incision in the 2 groups. By univariate analysis, minimally invasive surgery was a significant predictor of developing a postoperative peripheral neuropathy (Table 5). Age, lithotomy positioning, operative time, and Pfannenstiel incisions also were significantly related to neuropathy. Multivariate analysis evaluated the type of procedure, incision, length of stay, sex, age, BMI, diabetes mellitus,
patient position, operating time, and cancer diagnosis. Logistic regression analysis revealed only increased BMI to be a significant and independent predictor of developing postoperative neuropathy (p = 0.016; Table 6). An average BMI of 29 ± 8 was associated with postoperative neuropathy (independent t test). Although not statistically significant, there was a trend toward laparoscopic surgery being a risk factor for postoperative neuropathy (p = 0.066).
DISCUSSION Peripheral nerve injury after major colorectal surgery is a rare complication. Significant motor deficits, although Table 2. Cases of postoperative peripheral neuropathy Cases (n = 23) Mean age, y Male sex Diagnosis Diverticular disease Colon cancer Rectal cancer Ulcerative colitis Rectal prolapse Other neoplasma Operative approach Laparoscopic Robotic Open Operation Left/sigmoid colectomy LAR/APR Right colectomy Total colectomy Neuropathy Upper extremity Lower extremity Time to resolution of symptoms During hospitalization 1–4 wk 5 wk to 5 mo 6–12 mo
56 10 7 5 4 1 1 5 16 6 1 11 7 4 1 16 7 7 10 4 2
LAR = low anterior resection; APR = abdominoperineal resection. There were no motor deficits or permanent sensory deficits in these cases. a Other includes adenomas, carcinoid, and metastatic ovarian cancer.
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VELCHURU ET AL: ABDOMINAL SURGERY AND PERIPHERAL NEUROPATHY
Table 3. Details of patients, operations, neuropathy, and outcomes Age, y Sex Diagnosis
Operation
Neuropathy
Outcome
62 45 61
F Colon cancer F Chronic ulcerative colitis M Colon cancer
Laparoscopic right hemicolectomy Laparoscopic total colectomy Laparoscopic right hemicolectomy
56
F
59 48
M F
62
M
52 59 84 65
F F M F
74
M Rectal cancer
Robotic coloanal
75 62 47 40 36
F Colon polyp M Rectal cancer F Rectal cancer/right colonic cancer M Diverticulitis M Diverticulitis
42
F Rectal prolapse
56 59
F Diverticulitis F Diverticulitis
52 45 49
M Rectal cancer M Diverticulitis F Diverticulitis with colovaginal fistula
Laparoscopic right hemicolectomy Robotic coloanal Open low anterior resection and right hemicolectomy Laparoscopic low anterior resection Right ulnar neuropathy Laparoscopic low anterior resection Right median nerve and leg neuropathy Laparoscopic rectal resection Right lateral femoral rectopexy cutaneous neuropathy Robotic low anterior resection Right ulnar neuropathy Robotic low anterior resection Right median neuropathy and left thigh numbness Robotic assisted APR/sacrectomy Left ulnar neuropathy Laparoscopic low anterior resection Right median neuropathy Laparoscopic sigmoid resection Left radial neuropathy
Right brachial plexus Left femoral nerve Right lateral femoral cutaneous nerve Sigmoid diverticulitis Laparoscopic sigmoid resection Right femoral nerve and right ulnar nerve Rectal villous adenoma Laparoscopic low anterior resection Right median nerve Sigmoid diverticulitis Laparoscopic sigmoid resection Right lateral femoral cutaneous nerve Carcinoid of the appendix Laparoscopic right hemicolectomy Right genitofemoral nerve and right testicular pain Rectal tubulovillous adenoma Laparoscopic low anterior resection Right radial nerve Colon cancer Laparoscopic sigmoid resection Right femoral nerve Colon cancer Laparoscopic sigmoid resection Left ulnar nerve Rectal cancer Robotic low anterior resection Right hand numbness Right brachial plexus neuropathy Left ulnar nerve Right hand numbness Bilateral femoral neuropathy
Resolved before discharge Resolved at 5 mo Resolved at 1 mo Resolved at 6 wk Resolved at 2 wk Resolved in 7 mo Resolved at 12 mo Resolved at 1 wk Resolved before discharge Resolved at 4 wk CT head, normal; resolved before discharge Symptoms resolved in 4 wk; needed physiotherapy Resolved at 7 wk Resolved before discharge Resolved at 4 wk Resolved at 2 wk Resolved before discharge Resolved before discharge Resolved at 2 wk Resolved before discharge Resolved at 1 wk Resolved at 2 wk Resolved in 20 wk
F = female; M = male; APR = abdominoperineal resection.
rare, have been reported.4–6 Such injuries require intense physical therapy to regain function and may profoundly affect quality of life. With the advent of minimally invasive surgery, the number of colorectal operations performed
laparoscopically has increased exponentially. The Clinical Outcomes of Surgical Therapy trial demonstrated that oncologic outcomes of laparoscopic resections for cancer are no worse than those with open resections.11
Table 4. Demographics: minimally invasive surgery vs open surgery
Age, y Male sex Diabetes mellitus Arthritis Lithotomy position Pfannenstiel incision BMI, kg/m2 Operative time, min Length of stay, d Neuropathy
Minimally invasive (n = 1111)
Open (n = 403)
p
62.2 (17.6) 542 (48.78) 120 (10.8) 176 (15.8) 679 (61.1) 566 (50.9) 26.9 (5.6) 200 (94.2) 6.1 (3.5) 22 (1.98)
57.8 (19.9) 195(48.3) 48 (11.9) 57 (14.1) 109 (27) 0 25.9 (5.9) 139 (89.4) 6.7 (4.3) 1 (0.4)
0.001a 0.426b 0.008b 0.216b < 0.001b
Obesity Increases the Risk of Postoperative Peripheral Neuropathy After Minimally Invasive Colon and Rectal Surgery Vamsi R. Velchuru, F.R.C.S.(Edinb.), F.R.C.S.(Gen. Surg.)1 Bastian Domajnko, M.D. 2 • Ashwin deSouza, M.D.1 • Slawomir Marecik, M.D.1 Leela M. Prasad, M.D., M.S., F.R.C.S.(Edinb.), F.R.C.S.(C.)1 • John J. Park, M.D.1 Herand Abcarian, M.D.3,4 1 Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois 2 Rochester Colon & Rectal Surgeons, P.C., Rochester, New York 3 Division of Colon and Rectal Surgery, University of Illinois at Chicago Medical Center, Chicago, Illinois 4 Division of Colon and Rectal Surgery, John H Stroger Hospital of Cook County, Chicago, Illinois
BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively
maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. Financial Disclosure: None reported. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Tripartite Meeting (Early Results), Boston, MA, June 7 to 11, 2008. Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: Vamsi R. Velchuru, F.R.C.S.(Edinb.), F.R.C.S.(Gen. Surg.), James Paget University Hospitals, Lowestoft Road, Great Yarmouth, United Kingdom NR31 6LA. E-mail: [email protected] Dis Colon Rectum 2014; 57: 187–193 DOI: 10.1097/DCR.0000000000000037 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 2 (2014)
PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twentythree patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk
187
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ostoperative peripheral nerve injury is an uncommon but potentially significant complication of major surgery. The incidence of postoperative nerve injury ranges from 1 in 50 to 1 in 1000 patients undergoing general anesthesia1–3; however, the exact incidence is unknown. The etiology of postoperative neuropathy is multifactorial, although most cases are thought to be attributed to patient positioning, stretching, or compression of nerves and inadequate protection of susceptible sites. Abdominal wall retractors have also been implicated in causing nerve injuries.4–6 The majority of cases described are ulnar nerve injuries; however, there are reports describing injuries involving the brachial plexus, radial, femoral, sciatic, and common peroneal nerves.1–7 Femoral neuropathy has been well described in patients who have undergone abdominal operations, in particular those undergoing pelvic surgery requiring the use of Pfannenstiel incisions8 and abdominal wall retractors. Clinical features of postoperative nerve injury range from a mild self-limiting sensory disturbance to a profound and disabling sensorimotor deficit and can be a medicolegal issue.9,10 Major laparoscopic surgery requires unique positioning and steep tilt of the patient with longer operating times, resulting in a potential increase in the incidence of peripheral nerve injury compared with open operations. To date, no large studies exist that examined the prevalence of postoperative neuropathy after minimally invasive colon and rectal surgery (MIS). The objective of the study was to compare the incidence of postoperative peripheral neuropathy in minimally invasive versus open colon and rectal operations. Our goal was to review the outcomes after postoperative neuropathy and to identify risk factors for nerve injury.
robotic surgeries. All of the operations were performed by 1 of 3 board-certified colon and rectal surgeons in a community-based teaching hospital. Operations included colon and rectal resections for both benign and malignant disease. Demographics, operative details, and in-hospital and follow-up data were extracted from hospital medical and office charts. Postoperative neuropathy was defined as any symptom or sign of nerve injury (eg, anesthesia, paresthesia, hyperesthesia, pain, or paresis in a specific nerve distribution) occurring at any time after surgery, starting immediately in the postoperative period. Potential risk factors for nerve injury were also evaluated. These included sex, age, BMI, presence of diabetes mellitus or arthritis, patient positioning (lithotomy vs supine), incision type for specimen extraction (Pfannenstiel vs midline), and operative time. A standard technique of patient positioning was used throughout the study period. Operations were performed either in the supine position (for right hemicolectomy or stoma formation) or in modified lithotomy (for left colectomy, sigmoid resection, low anterior resection, and total colectomy). Securing of the patient was always undertaken by the operating surgeon. All of the laparoscopic and robotic operations involved the use of a bean bag with the arms tucked at the sides. Both arms were well padded, especially at bony prominence of the elbows and wrist. These help in protecting the nerves against the hardened bean bag during steep positioning. Padded shoulder supports were used to prevent the patient from sliding down the table. Patients were firmly secured at the chest to the table with tape. Padded Allen stirrups were used for patients in the modified lithotomy position, and care was taken to minimize pressure on the peroneal nerve. Pfannenstiel incisions were used for specimen extraction or hand-port placement in the majority of MIS cases. Midline incisions were used for open procedures. Approval for this study was granted by the institutional review board of Advocate Lutheran General Hospital. Statistical analysis was performed using SPSS version 19 (IBM SPSS Statistics, Chicago, IL). χ2 and Fisher exact test were used for categorical data. Continuous data were analyzed with the Student t test or the Mann-Whitney U test. Forward stepwise logistic regression was used for multivariate analysis. A p < 0.05 was considered statistically significant.
METHODS
RESULTS
A retrospective review of a prospectively maintained single-institution database of consecutive patients undergoing minimally invasive and open colon and rectal operations between March 2004 and April 2011 was performed. Patient complications, including postoperative neuropathy, were gathered in a prospective database. MIS included laparoscopic, hand-assisted laparoscopic, and
A total of 1514 abdominal colorectal operations were performed over a 7-year period. Of those, 1111 procedures (73.4%) were minimally invasive; these included laparoscopic (n = 479), hand-assisted laparoscopic (n = 466), and robotic (n = 166) operations. A total of 403 cases (26.6%) were performed as open surgery. The number of MIS cases increased each year, a statistically significant finding
of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures. KEY WORDS: Laparoscopic surgery; Neuropathy; Robotic
surgery.
P
189
Diseases of the Colon & Rectum Volume 57: 2 (2014)
Table 1. Procedures performed Laparoscopic (n = 945) Right colectomy Left colectomy/sigmoid colectomy Low anterior resection/APR/rectopexy IPAA/total/subtotal colectomy Small bowel resection Colostomy/ileostomy formation Colostomy/ileostomy reversal Othera
Robotic (n = 166)
301 22 453 87 12 53 0 17
50 3 107 6 0 0 0 0
Open (n = 403) 40 16 69 28 32 10 152 56
APR = abdominoperineal resection. a Other includes adhesiolysis, ventral hernia repairs, diagnostic procedures, and other partial colectomy.
(linear-by-linear association, p = 0.002). Table 1 lists the type of operations performed with each technique. Twenty-three of 1514 patients (1.5%) developed peripheral neuropathy in the postoperative period (Table 2). Table 3 illustrates the types of neuropathy and the outcomes. All but 1 case occurred in patients undergoing laparoscopic or robotic surgery. The mean patients age was 56 years (range, 46–84 years). Most of the neuropathy occurred in the upper extremities (n = 16). Sixteen cases were right-sided injuries, 5 were left sided, and 2 patients had bilateral injuries. Nerves injured included the median, radial, ulnar, femoral, lateral femoral cutaneous, and genitofemoral nerves (Table 3). Two patients had a brachial plexus neuropathy and 3 patients had 2 different nerve injuries simultaneously. Bilateral common peroneal nerve injuries were noted in the patient who had open surgery. In all of the cases, symptoms of nerve injury were sensory (eg, anesthesia, paresthesias, or hyperesthesia). One patient had concurrent motor deficit. Symptoms developed in the immediate postoperative period. Symptoms resolved preceding discharge in 7 patients, within 4 weeks of discharge in 10 patients, within 5 months in 4 patients, and within a year for the remaining 2 patients. None of the patients had a significant disabling neuropathy that affected quality of life. Demographics and outcomes were compared between the MIS group and the open group (Table 4). Patients undergoing laparoscopic or robotic surgery had a significantly higher incidence of postoperative neuropathy compared with patients undergoing open surgery (p = 0.015). There were also statistically significant differences in the incidence of diabetes mellitus, age, operative time, patient positioning (lithotomy), BMI, and the use of a Pfannenstiel incision in the 2 groups. By univariate analysis, minimally invasive surgery was a significant predictor of developing a postoperative peripheral neuropathy (Table 5). Age, lithotomy positioning, operative time, and Pfannenstiel incisions also were significantly related to neuropathy. Multivariate analysis evaluated the type of procedure, incision, length of stay, sex, age, BMI, diabetes mellitus,
patient position, operating time, and cancer diagnosis. Logistic regression analysis revealed only increased BMI to be a significant and independent predictor of developing postoperative neuropathy (p = 0.016; Table 6). An average BMI of 29 ± 8 was associated with postoperative neuropathy (independent t test). Although not statistically significant, there was a trend toward laparoscopic surgery being a risk factor for postoperative neuropathy (p = 0.066).
DISCUSSION Peripheral nerve injury after major colorectal surgery is a rare complication. Significant motor deficits, although Table 2. Cases of postoperative peripheral neuropathy Cases (n = 23) Mean age, y Male sex Diagnosis Diverticular disease Colon cancer Rectal cancer Ulcerative colitis Rectal prolapse Other neoplasma Operative approach Laparoscopic Robotic Open Operation Left/sigmoid colectomy LAR/APR Right colectomy Total colectomy Neuropathy Upper extremity Lower extremity Time to resolution of symptoms During hospitalization 1–4 wk 5 wk to 5 mo 6–12 mo
56 10 7 5 4 1 1 5 16 6 1 11 7 4 1 16 7 7 10 4 2
LAR = low anterior resection; APR = abdominoperineal resection. There were no motor deficits or permanent sensory deficits in these cases. a Other includes adenomas, carcinoid, and metastatic ovarian cancer.
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Table 3. Details of patients, operations, neuropathy, and outcomes Age, y Sex Diagnosis
Operation
Neuropathy
Outcome
62 45 61
F Colon cancer F Chronic ulcerative colitis M Colon cancer
Laparoscopic right hemicolectomy Laparoscopic total colectomy Laparoscopic right hemicolectomy
56
F
59 48
M F
62
M
52 59 84 65
F F M F
74
M Rectal cancer
Robotic coloanal
75 62 47 40 36
F Colon polyp M Rectal cancer F Rectal cancer/right colonic cancer M Diverticulitis M Diverticulitis
42
F Rectal prolapse
56 59
F Diverticulitis F Diverticulitis
52 45 49
M Rectal cancer M Diverticulitis F Diverticulitis with colovaginal fistula
Laparoscopic right hemicolectomy Robotic coloanal Open low anterior resection and right hemicolectomy Laparoscopic low anterior resection Right ulnar neuropathy Laparoscopic low anterior resection Right median nerve and leg neuropathy Laparoscopic rectal resection Right lateral femoral rectopexy cutaneous neuropathy Robotic low anterior resection Right ulnar neuropathy Robotic low anterior resection Right median neuropathy and left thigh numbness Robotic assisted APR/sacrectomy Left ulnar neuropathy Laparoscopic low anterior resection Right median neuropathy Laparoscopic sigmoid resection Left radial neuropathy
Right brachial plexus Left femoral nerve Right lateral femoral cutaneous nerve Sigmoid diverticulitis Laparoscopic sigmoid resection Right femoral nerve and right ulnar nerve Rectal villous adenoma Laparoscopic low anterior resection Right median nerve Sigmoid diverticulitis Laparoscopic sigmoid resection Right lateral femoral cutaneous nerve Carcinoid of the appendix Laparoscopic right hemicolectomy Right genitofemoral nerve and right testicular pain Rectal tubulovillous adenoma Laparoscopic low anterior resection Right radial nerve Colon cancer Laparoscopic sigmoid resection Right femoral nerve Colon cancer Laparoscopic sigmoid resection Left ulnar nerve Rectal cancer Robotic low anterior resection Right hand numbness Right brachial plexus neuropathy Left ulnar nerve Right hand numbness Bilateral femoral neuropathy
Resolved before discharge Resolved at 5 mo Resolved at 1 mo Resolved at 6 wk Resolved at 2 wk Resolved in 7 mo Resolved at 12 mo Resolved at 1 wk Resolved before discharge Resolved at 4 wk CT head, normal; resolved before discharge Symptoms resolved in 4 wk; needed physiotherapy Resolved at 7 wk Resolved before discharge Resolved at 4 wk Resolved at 2 wk Resolved before discharge Resolved before discharge Resolved at 2 wk Resolved before discharge Resolved at 1 wk Resolved at 2 wk Resolved in 20 wk
F = female; M = male; APR = abdominoperineal resection.
rare, have been reported.4–6 Such injuries require intense physical therapy to regain function and may profoundly affect quality of life. With the advent of minimally invasive surgery, the number of colorectal operations performed
laparoscopically has increased exponentially. The Clinical Outcomes of Surgical Therapy trial demonstrated that oncologic outcomes of laparoscopic resections for cancer are no worse than those with open resections.11
Table 4. Demographics: minimally invasive surgery vs open surgery
Age, y Male sex Diabetes mellitus Arthritis Lithotomy position Pfannenstiel incision BMI, kg/m2 Operative time, min Length of stay, d Neuropathy
Minimally invasive (n = 1111)
Open (n = 403)
p
62.2 (17.6) 542 (48.78) 120 (10.8) 176 (15.8) 679 (61.1) 566 (50.9) 26.9 (5.6) 200 (94.2) 6.1 (3.5) 22 (1.98)
57.8 (19.9) 195(48.3) 48 (11.9) 57 (14.1) 109 (27) 0 25.9 (5.9) 139 (89.4) 6.7 (4.3) 1 (0.4)
0.001a 0.426b 0.008b 0.216b < 0.001b
