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Laparoscopic Versus Open Colectomy: Case Selection and Techniques

Laparoscopic Versus Open Colectomy: Case Selection and Techniques. Anthony J. Senagore, MD, MBA, MS, FACS, FASCRS Vice President and Chief Academic Officer Spectrum Health Medical Group Professor of Surgery Michigan State University College of Human Medicine East Lansing, Michigan.

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Laparoscopic Versus Open Colectomy: Case Selection and Techniques

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  1. Laparoscopic Versus Open Colectomy:Case Selection and Techniques Anthony J. Senagore, MD, MBA, MS, FACS, FASCRS Vice President and Chief Academic Officer Spectrum Health Medical Group Professor of Surgery Michigan State University College of Human Medicine East Lansing, Michigan

  2. Faculty Disclosure It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity. Dr. Senagore has received grants/research support from Deltex Medical, ElectroCore Medical, LifeCell Corporation, and NiTi Surgical Solutions. He has served as a consultant for Ethicon, Inc and Tranzyme Pharma and has received honoraria from Adolor, Covidien, and GlaxoSmithKline.

  3. Educational Learning Objectives Describe the importance of improving time to gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice

  4. Initial Case Presentation • 65-year-old AA male diagnosed with a 4 cm, nonobstructing adenocarcinoma of the sigmoid colon (at 40 cm) • Meds: atenolol; simvastatin • Past history • Surgery: tonsillectomy & adenoidectomy; laparoscopic cholecystectomy • Medical: hypertension; hyperlipidemia

  5. The Colectomy Package • Preoperative evaluation • Prehabilitation • Operative care • SCIP – infectious prophylaxis • Fluid management • Minimally invasive surgery • Enhanced recovery protocol SCIP: Surgical Care Improvement Project

  6. Preoperative Evaluation:Surgical Risk • ASA score • ECG • Complete blood count and complete metabolic panel • Type and screen • Carcinoembryonic antigen1 • If elevated conveys higher risk of metastatic failure especially if fails to return to normal after surgery Goldstein M, Mitchell E. Cancer Invest. 2005;23(4):338-351.

  7. Patient Case–Staging Workup • Chest X-ray normal • Computed tomography (CT) scan • No evidence of metastatic disease; thickening of mid-sigmoid consistent with lesion • Positron emission tomography (PET) scan • No clear indication in primary colon cancer

  8. Tumor Staging • Survival (5-year by Dukes stage) • A = 90–95% • B = 70–80% • C = 55–65% • D = 5%

  9. Preoperative Education

  10. Educational Imperatives • Review pertinent risks and indications for procedure • Discuss anticipated recovery milestones (on instruction sheet) • Review anticipated discharge criteria • Assure access to follow-up and questions

  11. Surgical Options: Sigmoid Colectomy • Laparoscopic surgery • Probably preferred approach with training and experience • Hand-assisted laparoscopic surgery • May have shorter/different learning curve compared to straight lap • Open surgery • Standard approach

  12. What are the advantages of laparoscopic versus open colorectal surgery?

  13. Risk Reduction

  14. Laparoscopic Colorectal SurgeryMorbidity/Mortality Lumley J, et al. Dis Colon Rectum. 1996;39(2):155-159. Franklin M, et al. Dis Colon Rectum. 1996;39(10S):S35-46. Reissman P, et al. World J Surg. 1996;20(3):277-281. Bennett C, et al. Arch Surg. 1997;132(1):41-44. Senagore A, Delaney C. Am J Surg. 2006;191:377-380.

  15. POSSUM Score:Laparoscopic (LAP) Colectomy POSSUM: Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity Expected mortality rates based on either POSSUM or Porstmouth POSSUM scoring systems Op score: score for open colectomy, with 4 being the standard score Senagore AJ, et al. Br J Surg. 2003;90:1280-1284.

  16. Laparoscopic vs Open Colectomy17735 open vs 709 lap (Nationwide Inpatient samples) • Wound complications less (2% vs 1%) • Pulmonary complications less (6.2% vs 2.5%) • Cardiovascular complications less (2.4% vs 0.7%) • Mortality less (2.5% vs 0.3%) • LOS less (9.3 vs 5.7 days) Guller U, et al. Arch Surg. 2003;138:1179-1186.

  17. Short-term Benefits of Laparoscopic vs Open Surgery for Colorectal Resection • Meta-analysis of 22 trials (n= 2965) of colorectal surgery • Reduced blood loss of 71.8 mL (95% CI, 30.8-113 mL; P = 0.0006) • Reduced postoperative painby 9.3/100 (95% CI, 5.4-13.2; P < 0.0001) • Earlier flatulenceby 1 day (95% CI, 0.76-1.3; P < 0.0001) • Earlier bowel movementby 0.9 days (95% CI, 0.74-1.13; P < 0.0001) • Lessened ileus(RR = 0.40 95% CI, 0.22-0.73; P = 0.003) • Reduced wound infections (RR = 0.56 95% CI, 0.39-0.89; P = 0.002) • Shortened hospital length of stay (LOS) by 1.5 days (95% CI, 1.12-1.94; P < 0.0001) Schwenk W, et al. Cochrane Database Syst Rev. 2005;CD003145.

  18. Incidence of Hernia/Small Bowel Obstruction:CCF Index Segmental Colectomies LABS OPENP-value* 211 (100%) 505 (100%) Hernia 5 (2.4%) 65 (12.9%) 0.00002 Reoperation for Hernia 4 (1.9%) 28 (5.5%) 0.03 SBO (non-surgical treatment) 4 (1.9%) 31 (6.1%) 0.016 SBO (surgical treatment)3 (1.4%) 8 (1.6%) 0.87 LABS: laparoscopic-assisted bowel resection *Chi-square Test Duepree HJ, et al. J Am Coll Surg. 2003;197:177-181. CCF: Cleveland Clinic Foundation

  19. Laparoscopic Colorectal Surgery • Compared with open colorectal surgery, laparoscopic surgery is associated with • Reduced surgical trauma • Reduced postoperative morbidity/complications • Reduced postoperative pain • Earlier passage of flatus and earlier bowel movement • Reduced length of hospital stay • Similar oncologic outcome

  20. Standardized Technique:Laparoscopic Sigmoid Colectomy • Medial approach to vascular pedicle • Identification of left ureter from IMA origin to pelvic inlet • Division of proximal vascular pedicle (IMA) • Mobilization of mesocolon off retroperitoneum to the lateral attachments • Lateral release of desc/sigmoid colon • Release of splenic flexure (if needed) • Mobilization/division of proximal rectum • Exteriorization of specimen via LLQ muscle splitting incision with wound protector • Primary end-to-end colorectal anastomosis IMA: inferior mesenteric artery; LLQ: left lower quadrant Senagore AJ. Surg Clin N Am. 2005;85:19-24.

  21. Medial Approach to Left Ureter IMA IMA: inferior mesenteric artery

  22. Medial Approach to Left Ureter Left Ureter

  23. Inferior Mesenteric Artery Pedicle

  24. Vascular Division

  25. Completed Dissection

  26. Rectal Transection

  27. Obesity (BMI > 30) Inflammatory Masses Adhesions Intraoperative complications Bleeding Bowel injury Odds ratios (900 cases) BMI 1.07 ASA score 1.63 Left vs right colorectal procedures 1.5 Abscess 5.0 Enteric fistula 4.6 Experience 0.9 per 10 additional cases Predictors of ConversionLaparoscopic to Open Surgery TekkisP, et al. Ann Surg. 2005;242:83-91.

  28. Non-obese (BMI < 30) Conversion: 11% Morbidity: 13% Leak rate: 1% Obese (BMI ≥ 30) Conversion: 24% Morbidity: 22% Leak rate: 5% Laparoscopic ColectomyImpact of Obesity Senagore AJ, et al. J Gastrointest Surg. 2003;7:558-561.

  29. 45 40 35 30 25 20 15 10 5 0 Reasons for Conversion Technical Adhesions Infection % Bleeding Ureter identification Casillas S, et al. Dis Colon Rectum. 2004;47(10):1680-1685.

  30. Stage of Conversion Presacral dissection/ bowel transection Prior to vascular pedicle/ ureter identification 35% 50% 15% Related to intracorporeal vascular ligation Casillas S, et al. Dis Colon Rectum. 2004;47(10):1680-1685.

  31. What are the postoperative elements of an enhanced recovery pathway?

  32. Enhanced Recovery Pathway Standardized Order Set

  33. Enhanced Recovery Pathway (ERP) Key Postoperative Components • No routine NG tubes • Foley out first day • Narcotic-sparing analgesics • Ibuprofen 800 mg po q 8 hrs • Gabapentin 300 mg po q 8 hrs • Early ambulation • Early resumption of diet

  34. National Surgical Quality Improvement Program (NSQIP) Length of Stay Analysis Cohen ME, et al. Ann Surg. 2009;250:901-907.

  35. Enhanced Recovery Pathway (ERP) Impact on Length of Stay (LOS) 1991–1999 1999 March–June/2000 n LOS n LOS n LOS DRG 148 ERP open 1784 9.5 185 8.6 62 5.7* other CR teams 6459 9.8 824 8.8 162 10.1 ERP/lap 243.2* DRG 149 ERP open 742 6.4 69 5.2 44 3.5† other CR teams 2256 6.4 327 5.1 111 4.5 ERP/lap 18 2.5* DRG 148 & 149 ERP open 2526 8.6 254 7.7106 4.7§ other CR teams 8715 8.9 1151 7.7 273 7.7 ERP/lap 42 2.9 * * P < 0.0001; † P = 0.002; §P < 0.001, Student’s t test LAP: laparoscopy CR: colorectal surgery Delaney C,et al. Br J Surg. 2001;88:1533-1538.

  36. “The 48-Hour Colectomy”

  37. “The 23-Hour Colectomy”

  38. Outcome of Unplanned Readmission (UR)(DRG Codes 146 to 149) • 553 colorectal resections in 6 months; 56 UR (10%) • No predictors (complications, WBC, hemoglobin, antibiotics, comorbidity, fever, urgency of procedure, presence of a stoma, length of stay) • Matched non-readmitted cases had shorter primary LOS (6 vs 5 days, P = 0.049) • UR had more perioperative steroids (32 vs 17%, P = 0.03) • No adverse event related to delayed diagnosis • Conclusion: unplanned readmission is unpredictable, not related to LOS, and doesn’t affect overall outcome Kiran RP, et al. J Am Coll Surg. 2004;198:877-883.

  39. Patient Case Continued • Patient underwent a laparoscopic sigmoid colectomy • Transitioned to oral ibuprofen and gabapentin on POD 1 • Resumption of a general diet on POD 1 • Discharged without complications after having a bowel movement on POD 2

  40. Enhanced Recovery Pathway Key Components • Laparoscopic approach preferred • No routine NG tubes • Foley out first day • Narcotic sparing analgesics • Ibuprofen 800 mg po q 8 hrs • Gabapentin 300 mg po q 8 hrs • Consider alvimopan where appropriate to reduce POI risk • Early ambulation • Early resumption of diet

  41. Why It Works • Fast-track pathways are a win-win situation • Include all groups • Nurses (including enterostomal therapy nurses), residents, pharmacists, surgeons, anesthesiologists • Evidence-based decisions not compromise and consensus

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