S1048 Laparoscopy and/or Fast Track Multimodal Management Versus Open and/or Standard Care in Colonic Surgery (LAFA-Trial)

Abstract

Bacterial translocation may occur during abdominal surgery. Intestinal ischemia impairs the intestinal barrier function, thereby enhancing intestinal permeability and bacterial translocation. Total colectomies are performed both open and laparoscopically. In open surgery devascularisation is performed after mobilization of the bowel, whereas the medial to lateral laparoscopic approach starts with left-sided (inferior mesenteric artery; IMA) or right-sided (ileocolic artery; ICA) devascularisation. Aim is to determine whether the type of approach, open or laparoscopic, and the order of devascularisation in laparoscopic colectomy, affects intestinal barrier function, local inflammatory response and clinical outcome. Elective colectomy patients were included from April 2006 to July 2008. After informed consent, 22 patients scheduled for laparoscopic colectomy were randomized to start with IMA or ICA devascularisation. Eigtheen patients scheduled for open surgery served as a prospective control group. To assess the intestinal barrier function polyethylene glycol recovery (PEG; marker of intestinal permeability) and release of intestinal fatty acid binding protein (IFABP; marker of mucosal ischemia) were measured preand postoperatively. Mesenteric lymph nodes were harvested to assess expression of inflammatory mediator-related genes using Multiplex Ligation Probe Amplification. Right-sided start of devascularisation significantly increased excretion of I-FABP over time (P=0.005). Compared to pre-operative values increased I-FABP levels were found on postoperative days 1 and 3 (P=0.009 and P=0.002, respectively). There were no differences in PEG recovery, expression of inflammatory mediator-related genes or post-operative morbidity among the groups. In conclusion, a rightsided start of devascularisation during laparoscopic colectomy is associated with more intestinal mucosal ischemia. For this reason devascularisation starting at the IMA during laparoscopic colectomy may be preferred. There are no clinical consequences demonstrated in this small series.