J Gastrointest Surg (2014) 18:1010–1016 DOI 10.1007/s11605-014-2491-7
ORIGINAL ARTICLE
The Best Surgical Approach for Left Colectomy: A Comparative Study Between Transverse Laparotomy, Midline Laparotomy and Laparoscopy Frédéric Borie & Jean-Marc Bigourdan & Marie-Hélène Pissas & Jeremy Ripoche & Bertrand Millat
Received: 20 November 2013 / Accepted: 27 February 2014 / Published online: 14 March 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Aim To compare the early and late complications after left colectomy (LC) by left transverse laparotomy (LTL), midline laparotomy (ML) and laparoscopy (La). Methods From 1998 to 2003, 328 patients underwent an LC by LTL, ML or La. After matching patients for age, ASA score and indication, 159 patients were divided into three groups of 53 patients each according to the surgical approach performed. The median follow-up was 8 years. Early and late complications were compared by univariate and multivariate analysis. Results Early morbidity rates after LTL, ML and La were 52 %, 45 % and 21 %, respectively (p=0.002). Extra digestive complication rates after LTL, ML and La were 36 %, 34 % and 13.2 %, respectively (p=0.02). Respiratory complication rates were 15 %, 21 % and 2 % (p=0.01). The rate of wound infection was higher after LTL (15 % vs. 6 % and 6 %, p=0.06). Length of stay was significantly shorter after La (median: LTL, 10 days; ML, 9 days; La, 6 days; p0.1 for other factors). Among the six patients with septicemia, four (2 in Lap and 2 in ML) were Gram-negative Bacillus infections due to poorly tolerated fistula and two others in the LTL group were due to central venous lines infections (one due to Klebsiella
The median hospital stay was 10 days (3–32) in the LTP group, 9 days (5–34) in the ML group, significantly longer than in the La group (6 days (4–30)), p30 Eventration Same laparotomy Indication Cancer Benign Surgery Rapidly resorbable suture Non resorbable suture Postoperative complications
53 53 53
7 4 12
13 % 8% 23 %
40 119 68 29 52 18 11 30
3 20 14 7 10 2 4 4
82 77
Wound complications Respiratory complications Fistula Morbidity
CI 95 % multivariate
Incision
Table 6 Obstructions and risk factors Total n Incision Laparoscopy 53 Transverse 53 Midline 53 History Age>70 years 40 Age1 83 Number of laparotomies >2 23 Fistula 15
n
%
p univariate
4 4 2
8 8 4
0.06
4 6 1
10 5 3
0.15 0.23
4 6 0
5 8 0
0.6
7 2 15
8 9 0
0.4 0.6 0.23
0.32
0.5-7
0.004
0.02
1.2-16
8% 17 % 21 % 24 % 20 % 10 % 36 % 13 %
0.15 0.06 0.15 0.37 0.73 0.05 0.23
NS 0.02 NS
1.3-9.3
9 14
11 % 18 %
0.2
NS
78 68
15 6
19 % 9%
0.07
NS
18 19 15 63
4 6 4 14
21 32 27 22
0.16 0.04 0.23 0.02
% % % %
NS
NS NS
There were five patients with prolonged ileus in the laparotomy groups compared with none in La, which might mean the surgical approach could interact with postoperative intestinal motility and peristalsis, dependent on digestive tract manipulations. Other factors — such as early refeeding, use of opioids, hyperhydration, factors of inflammation and pain management — are also known to play a major role on the ileus.13 This information was missing in our study, and early rehabilitation was not standardized during this period. Patients who underwent laparoscopy were perhaps more quickly solicited to move about and eat earlier, a potential factor in reducing morbidity.14. Postoperative complications are associated with prolongation of hospital stay.11 Length of stay was longer after laparotomy, probably due to increased morbidity. Regarding our main criteria, LTL had the lowest incisional hernia rate, regardless of the type of suture used. The fact that antecedent cardiovascular history emerged as an independent risk factor influencing parietal healing reinforces the benefits of the LTL, especially in patients at risk for complications and incisional hernia. The 8 % incisional hernia rate observed in our series was relatively low compared to that in the literature, especially with such a follow, up. The expected rate is usually between 15 % and 20 %. 5 17.
1016
The obstruction rate observed in our study (6.3 %) was lower than that described in the literature.15 Some authors consider the rate of readmission for acute episodes due to adhesions is more likely to be over 30 %.15 However, these events may occur long after surgery. Ellis,16 in a series of patients operated for mechanical obstruction, reported that more than 20 % of obstructions occurred more than 10 years after the index operation. In our study, the median follow-up was 8 years (range 3.7–9.5). The low incidence of obstruction was probably the reason why we found no difference between the types of incision. Nonetheless, laparoscopy does not appear to be superior in this respect. While this study seems to confirm that laparoscopy should be preferred in order to reduce extra digestive morbidity, laparotomy has its specific indications, either for conversion (10 % in our data base) or for patients with a contra-indication to laparoscopy. Whenever laparotomy is indicated, LTL reduces the risk of respiratory complications and incisional hernia and should be the method of choice in these conditions. Conflict of interest There are conflicts of interest.
References 1. Laparoscopic colectomies or colectomy by laparotomy with laparoscopic preparation, S.e.v.d.a. professionnels, Editor. 2007, Service évaluation des actes professionnels, Haute autorité de santé: Paris. 2. Brown, S.R. and P.B. Goodfellow, Transverse versus midline incisions for abdominal surgery. Cochrane Database Syst Rev, 2005(4): CD005199. 3. Seiler, C.M., Deckert A, Diener MK et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg, 2009. 249(6): p. 913–20.
J Gastrointest Surg (2014) 18:1010–1016 4. Aalbers, A.G., Doeksen A, Van Berge et al. Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review. Colorectal Dis, 2010. 12(4): 287–95. 5. Kuhry, E., Schwenk WF, Gaupset R et al. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev, 2008(2): CD003432. 6. Schwenk, W., Haase O, Neudecker J, et al. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev, 2005(3): p. CD003145. 7. Leung, K.L., Kwok SP, Lam SC, et al., Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet, 2004. 363(9416): p. 1187–92. 8. Mantion, G. Mortality and morbidity in colorectal surgery. Monographies de l'Association Francaise de Chirurgie, ed. Arnette. 2003, Rueil-Malmaison: Groupe Liaisons SA. 9. Gottrup, F. Oxygen in wound healing and infection. World J Surg, 2004. 28(3): 312–5. 10. Greif, R., Akça O, Horn EP, et al. Outcomes Research Group. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med, 2000. 342(3): p. 161–7 11. Tang, R., Chen HH, Wang YL et al., Risk factors for surgical site infection after elective resection of the colon and rectum: a singlecenter prospective study of 2,809 consecutive patients. Ann Surg, 2001. 234(2): p. 181–9. 12. Karim, H., Chafik K, Karim K, et al., Risk factors for surgical wound infection in digestive surgery. Retrospective study of 3,000 surgical wounds. Tunis Med, 2000. 78(11):634–40 13. Mattei, P. and Rombeau J.L., Review of the pathophysiology and management of postoperative ileus. World J Surg, 2006. 30(8): 1382–91. 14. Kehlet, H. and D.W. Wilmore D.W, Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg, 2008. 248(2): 189–98. 15. Parker, M.C., Ellis H, Moran BJ, Thompson JN, et al. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum, 2001. 44(6): 822–29; discussion 829–30. 16. Ellis, H. Postoperative intraabdominal adhesions: a personal view. Colorectal Dis, 2007, 9 Suppl 2: 3–8 17. Taylor GW, Jayne DG, Brown SR, et al. Br J Surg. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. 2010;97(1):70–8.
ORIGINAL ARTICLE
The Best Surgical Approach for Left Colectomy: A Comparative Study Between Transverse Laparotomy, Midline Laparotomy and Laparoscopy Frédéric Borie & Jean-Marc Bigourdan & Marie-Hélène Pissas & Jeremy Ripoche & Bertrand Millat
Received: 20 November 2013 / Accepted: 27 February 2014 / Published online: 14 March 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Aim To compare the early and late complications after left colectomy (LC) by left transverse laparotomy (LTL), midline laparotomy (ML) and laparoscopy (La). Methods From 1998 to 2003, 328 patients underwent an LC by LTL, ML or La. After matching patients for age, ASA score and indication, 159 patients were divided into three groups of 53 patients each according to the surgical approach performed. The median follow-up was 8 years. Early and late complications were compared by univariate and multivariate analysis. Results Early morbidity rates after LTL, ML and La were 52 %, 45 % and 21 %, respectively (p=0.002). Extra digestive complication rates after LTL, ML and La were 36 %, 34 % and 13.2 %, respectively (p=0.02). Respiratory complication rates were 15 %, 21 % and 2 % (p=0.01). The rate of wound infection was higher after LTL (15 % vs. 6 % and 6 %, p=0.06). Length of stay was significantly shorter after La (median: LTL, 10 days; ML, 9 days; La, 6 days; p0.1 for other factors). Among the six patients with septicemia, four (2 in Lap and 2 in ML) were Gram-negative Bacillus infections due to poorly tolerated fistula and two others in the LTL group were due to central venous lines infections (one due to Klebsiella
The median hospital stay was 10 days (3–32) in the LTP group, 9 days (5–34) in the ML group, significantly longer than in the La group (6 days (4–30)), p30 Eventration Same laparotomy Indication Cancer Benign Surgery Rapidly resorbable suture Non resorbable suture Postoperative complications
53 53 53
7 4 12
13 % 8% 23 %
40 119 68 29 52 18 11 30
3 20 14 7 10 2 4 4
82 77
Wound complications Respiratory complications Fistula Morbidity
CI 95 % multivariate
Incision
Table 6 Obstructions and risk factors Total n Incision Laparoscopy 53 Transverse 53 Midline 53 History Age>70 years 40 Age1 83 Number of laparotomies >2 23 Fistula 15
n
%
p univariate
4 4 2
8 8 4
0.06
4 6 1
10 5 3
0.15 0.23
4 6 0
5 8 0
0.6
7 2 15
8 9 0
0.4 0.6 0.23
0.32
0.5-7
0.004
0.02
1.2-16
8% 17 % 21 % 24 % 20 % 10 % 36 % 13 %
0.15 0.06 0.15 0.37 0.73 0.05 0.23
NS 0.02 NS
1.3-9.3
9 14
11 % 18 %
0.2
NS
78 68
15 6
19 % 9%
0.07
NS
18 19 15 63
4 6 4 14
21 32 27 22
0.16 0.04 0.23 0.02
% % % %
NS
NS NS
There were five patients with prolonged ileus in the laparotomy groups compared with none in La, which might mean the surgical approach could interact with postoperative intestinal motility and peristalsis, dependent on digestive tract manipulations. Other factors — such as early refeeding, use of opioids, hyperhydration, factors of inflammation and pain management — are also known to play a major role on the ileus.13 This information was missing in our study, and early rehabilitation was not standardized during this period. Patients who underwent laparoscopy were perhaps more quickly solicited to move about and eat earlier, a potential factor in reducing morbidity.14. Postoperative complications are associated with prolongation of hospital stay.11 Length of stay was longer after laparotomy, probably due to increased morbidity. Regarding our main criteria, LTL had the lowest incisional hernia rate, regardless of the type of suture used. The fact that antecedent cardiovascular history emerged as an independent risk factor influencing parietal healing reinforces the benefits of the LTL, especially in patients at risk for complications and incisional hernia. The 8 % incisional hernia rate observed in our series was relatively low compared to that in the literature, especially with such a follow, up. The expected rate is usually between 15 % and 20 %. 5 17.
1016
The obstruction rate observed in our study (6.3 %) was lower than that described in the literature.15 Some authors consider the rate of readmission for acute episodes due to adhesions is more likely to be over 30 %.15 However, these events may occur long after surgery. Ellis,16 in a series of patients operated for mechanical obstruction, reported that more than 20 % of obstructions occurred more than 10 years after the index operation. In our study, the median follow-up was 8 years (range 3.7–9.5). The low incidence of obstruction was probably the reason why we found no difference between the types of incision. Nonetheless, laparoscopy does not appear to be superior in this respect. While this study seems to confirm that laparoscopy should be preferred in order to reduce extra digestive morbidity, laparotomy has its specific indications, either for conversion (10 % in our data base) or for patients with a contra-indication to laparoscopy. Whenever laparotomy is indicated, LTL reduces the risk of respiratory complications and incisional hernia and should be the method of choice in these conditions. Conflict of interest There are conflicts of interest.
References 1. Laparoscopic colectomies or colectomy by laparotomy with laparoscopic preparation, S.e.v.d.a. professionnels, Editor. 2007, Service évaluation des actes professionnels, Haute autorité de santé: Paris. 2. Brown, S.R. and P.B. Goodfellow, Transverse versus midline incisions for abdominal surgery. Cochrane Database Syst Rev, 2005(4): CD005199. 3. Seiler, C.M., Deckert A, Diener MK et al. Midline versus transverse incision in major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg, 2009. 249(6): p. 913–20.
J Gastrointest Surg (2014) 18:1010–1016 4. Aalbers, A.G., Doeksen A, Van Berge et al. Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review. Colorectal Dis, 2010. 12(4): 287–95. 5. Kuhry, E., Schwenk WF, Gaupset R et al. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev, 2008(2): CD003432. 6. Schwenk, W., Haase O, Neudecker J, et al. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev, 2005(3): p. CD003145. 7. Leung, K.L., Kwok SP, Lam SC, et al., Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet, 2004. 363(9416): p. 1187–92. 8. Mantion, G. Mortality and morbidity in colorectal surgery. Monographies de l'Association Francaise de Chirurgie, ed. Arnette. 2003, Rueil-Malmaison: Groupe Liaisons SA. 9. Gottrup, F. Oxygen in wound healing and infection. World J Surg, 2004. 28(3): 312–5. 10. Greif, R., Akça O, Horn EP, et al. Outcomes Research Group. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med, 2000. 342(3): p. 161–7 11. Tang, R., Chen HH, Wang YL et al., Risk factors for surgical site infection after elective resection of the colon and rectum: a singlecenter prospective study of 2,809 consecutive patients. Ann Surg, 2001. 234(2): p. 181–9. 12. Karim, H., Chafik K, Karim K, et al., Risk factors for surgical wound infection in digestive surgery. Retrospective study of 3,000 surgical wounds. Tunis Med, 2000. 78(11):634–40 13. Mattei, P. and Rombeau J.L., Review of the pathophysiology and management of postoperative ileus. World J Surg, 2006. 30(8): 1382–91. 14. Kehlet, H. and D.W. Wilmore D.W, Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg, 2008. 248(2): 189–98. 15. Parker, M.C., Ellis H, Moran BJ, Thompson JN, et al. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum, 2001. 44(6): 822–29; discussion 829–30. 16. Ellis, H. Postoperative intraabdominal adhesions: a personal view. Colorectal Dis, 2007, 9 Suppl 2: 3–8 17. Taylor GW, Jayne DG, Brown SR, et al. Br J Surg. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. 2010;97(1):70–8.
