Laparoscopic Segmental Colectomy Research Articles

Laparoscopic segmental colectomy for a rare case of extraluminal amoeboma masquerading as stromal tumour of the colon

Abstract Entamoeba histolytica is known to cause infectious colitis that presents with diarrhoea or dysentery. Extra intestinal manifestations result in amoebic abscesses to involve organs such as the liver, lungs or brain. Very rarely, it may present like a pseudotumour due to a mass formation if the primary infection was untreated or inadequately treated. We, herein, report a rare case of extraluminal amoebic pseudotumour in a young female with a diagnosis of a gastrointestinal stromal tumour of hepatic flexure of the transverse colon on pre-operative imaging and per operative findings, but final histopathological examination of the resected specimen proved it to be an amoeboma. The rarity of this case was the extraluminal presentation, unlike other reported cases of intraluminal pseudotumour. After an extensive literature search, we believe that this is the first reported case of extraluminal pseudotumour of the transverse colon managed by laparoscopic segmental colectomy.

Short-term and long-term outcomes of intracorporeal anastomosis in laparoscopic segmental left colectomy for splenic flexure cancer - a multicenter retrospective cohort study of 342 cases.

While intracorporeal anastomosis (IA) has been widely used in totally laparoscopic right colectomy, its application in laparoscopic segmental left colectomy for splenic flexure cancer remains underexplored, particularly in large-scale studies with long-term outcomes. This research aims to assess the technical feasibility and oncological efficacy of IA in treating colonic splenic flexure carcinoma, drawing insights from both short-term and long-term outcomes of a retrospective cohort. A retrospective analysis was conducted on 342 patients diagnosed with colonic splenic flexure carcinoma in three Chinese medical centers. These patients underwent laparoscopic segmental left colectomy between December 2014 and December 2019 across three medical institutions. Comprehensive data encompassing demographics, disease features, pathological characteristics, operative details, and both short-term and long-term outcomes were gathered and scrutinized. Using propensity scores, each patient from the IA cohort was paired with a counterpart from the extracorporeal anastomosis (EA) cohort. IA was performed on 129 patients, while 213 underwent EA. Post-propensity score matching resulted in 129 matched pairs. After matching, many baseline characteristics were balanced. The IA cohort exhibited several advantages, including shorter incision lengths ( P <0.001) and more extensive proximal and distal resection margins ( P =0.003, P <0.001). Additionally, the IA method facilitated a more rapid postoperative recovery as indicated by quicker return of bowel movements (resumption of passing flatus [2.7 (1.0-7.0) days vs. 3.3 (2.0-8.0) days, P <0.001] and defecation [3.7 (1.0-9.0)] days vs. 4.5 (2.0-9.0) days, P <0.001]), faster discharges [6.6 (3.0-15.0) days vs. 8.3 (5.0-20.0) days, P <0.001], and decreased need for rescue analgesics ( P <0.001). The rate of postoperative complications, as rated by the Clavien-Dindo classification, remained consistent across both techniques ( P =0.087). Furthermore, the cosmetic outcome rated by Patient Scar Assessment Questionnaire and Scoring System (PSAQ) was markedly superior in the IA group ( P <0.001). Both approaches demonstrated equivalent 5-year overall (82.7% vs. 82.1%, P =0.419) and disease-free survival (80.9% vs. 78.1%, P =0.476). Subsequent stratification analysis revealed that IA achieved comparable 5-year overall (80.7% vs. 82.0%, P =0.647) and disease-free survival (78.1% vs. 76.4%, P =0.734) in patients with locally advanced colon cancer. Employing IA for laparoscopic segmental left colectomy in cases of splenic flexure carcinoma is not only safe but also offers enhanced cosmetic results and expedited postoperative recovery. Oncologically speaking, IA in left segmental colectomy for splenic flexure carcinoma can yield therapeutic outcomes comparable to those of EA, even in patients with locally advanced colon cancer.

Efficacy and safety of hybrid laparo-endoscopic surgery for colon tumors (systematic review and meta-analysis)

Aim: to compare the efficacy and safety of hybrid laparo-endoscopic operations and laparoscopic segmental colectomy for benign endoscopically non-removable colorectal tumors.Materials and Methods: systematic review and meta-analysis included 17 studies which evaluate the results of hybrid laparo-endoscopic procedure (main group) and laparoscopic segmental colectomy (control group). The study included 835 patients — 517 in main group and 318 controls.Results: operation time was significantly lower in main than in control group (mean difference = −38,7 minutes; 95% CI: −51,4 — −26, p &lt; 0,00001). There was significant difference in postoperative hospital stay. It was shorter in main group (mean difference = −2,3 days; 95% CI: −3,17 — −1,57, p &lt; 0,00001). There was not significant difference between odds ratio of postoperative morbidity (OR = 0,7; 95% CI: 0,38–1,53, p = 0,44), mortality (OR = 0,4; 95% CI: 0,07–3,11, p = 0,43) and local recurrence rate as well (OR = 2,8; 95% CI: 0,68–11,35, p = 0,15).Conclusion: the hybrid laparo-endoscopic technique patients with benign endoscopically non-removable colon tumors does not increase the postoperative morbidity and mortality. At the same time, the hybrid technology reduces the operation time and postoperative hospital stay.

Quality of Life After Videolaparoscopic Segmentary Colectomy For Intestinal Endometriosis

Background: Intestinal endometriosis (IE) is a chronic estrogen-dependent disease characterized by endometrial stroma outside the uterine cavity. It affects 10 to 15% of women and may present with pelvic pain and worsening quality of life. Treatment can be surgical, such as videolaparoscopic segmental colectomy (VSC). Objective: To evaluate the quality of life of patients after VSC for treatment of intestinal endometriosis. Method: This is an observational, longitudinal, and retrospective study carried out through a review of medical records and a telephone interview with patients who underwent laparoscopic segmental colectomy in a private hospital between 2016 and 2020. Results: 43 patients were studied, of whom 30 (70%) complained of having impaired daily activities. Before surgery, dysmenorrhea intensity was classified as mild, moderate, severe, and very severe pain, with one patient (2.33%) classified as mild, three patients (6.98%) as moderate, 16 patients (37.2%) as severe, and 23 (53.49%) as very severe. As for pain during sexual intercourse, 13 patients (30%) reported dyspareunia. After surgery, 100% of the patients reported improvement in the complaint, referring to maintaining a normal routine after the VSC; of the 13 patients who did not feel that they had any impairment in their daily activities before the surgery, 2 still reported feeling more lively in their routine after having undergone surgery (P&lt;.05). As for the intensity of dysmenorrhea after surgery, one (2.33%) patient classified it as moderate and 42 (97.67%) as mild (P&lt;.05), indicating that there is a difference in pain intensity before and after surgery. Of the patients who previously reported dyspareunia, it was observed that 100% of them reported improvement after VSC with P=.0002. Conclusion: CSV can improve the quality of life of patients with intestinal endometriosis.

Quality of Life After Video Laparoscopic Segmentary Colectomy for Intestinal Endometriosis

Background: Intestinal endometriosis (IE) is a chronic estrogen-dependent disease characterized by endometrial stroma outside the uterine cavity. It affects 10 to 15% of women and may present with pelvic pain and worsening quality of life. Treatment can be surgical, such as video laparoscopic segmental colectomy (VSC). Objective: To evaluate the quality of life of patients after VSC for treatment of intestinal endometriosis. Method: This is an observational, longitudinal, and retrospective study carried out through a review of medical records and a telephone interview with patients who underwent laparoscopic segmental colectomy in a private hospital between 2016 and 2020. Results: 43 patients were studied, of whom 30 (70%) complained of having impaired daily activities. Before surgery, dysmenorrhea intensity was classified as mild, moderate, severe, and very severe pain, with one patient (2.33%) classified as mild, three patients (6.98%) as moderate, 16 patients (37.2%) as severe, and 23 (53.49%) as very severe. As for pain during sexual intercourse, 13 patients (30%) reported dyspareunia. After surgery, 100% of the patients reported improvement in the complaint, referring to maintaining a normal routine after the VSC; of the 13 patients who did not feel that they had any impairment in their daily activities before the surgery, 2 still reported feeling more lively in their routine after having undergone surgery (P&lt;.05). As for the intensity of dysmenorrhea after surgery, one (2.33%) patient classified it as moderate and 42 (97.67%) as mild (P&lt;.05), indicating that there is a difference in pain intensity before and after surgery. Of the patients who previously reported dyspareunia, it was observed that 100% of them reported improvement after VSC with P=.0002. Conclusion: CSV can improve the quality of life of patients with intestinal endometriosis.

Full-Thickness Laparoendoscopic Excision for Management of Complex Colon Polyps.

Benign colon polyps are increasingly being detected because of improved colonoscopic screening and early detection of masses on the adenoma-to-carcinoma pathway. Full-thickness laparoendoscopic excision is a colon-preserving technique for endoscopically unresectable polyps consisting of endoscopically guided nonanatomic wedge colectomy. This study aimed to evaluate the safety and success of full-thickness laparoendoscopic excision compared to segmental colectomy for complex polyps not amenable to endoscopic resection. This is a retrospective case-control study. This study was conducted at a tertiary academic center. A prospectively maintained institutional database identified 22 patients with benign complex polyps managed with full-thickness laparoendoscopic excision from 2015 to 2020. These patients were compared with 22 propensity score-matched controls from the same database that underwent laparoscopic segmental colectomy. Primary outcome was inpatient length of stay. Secondary outcomes included operative details and postoperative morbidities. Full-thickness laparoendoscopic excision was successful in all patients. Patients had a median age of 64 years (41-85), and 82% were men. Final pathology revealed complete excision of benign lesions in 20 of 22 patients and adenocarcinoma in 2 of 22. For the adenocarcinomas, 1 patient underwent subsequent elective colectomy without complications, and 1 patient declined surgery. Propensity score matching was successful for age, sex, BMI, ASA score, colon location, and prior abdominal surgery. Compared with controls, cases had significantly shorter operative time (89.5 minutes (46-290) vs 122 minutes (85-200), p = 0.009), length of stay (1 day (0-17) vs 3 days (1-8), p < 0.001), and reduced blood loss (5 mL (2-15) vs 25 mL (10-150), p < 0.001). Thirty-day morbidity (9.1% vs 27.3%, p = 0.240) was not significantly different. An unplanned 30-day reoperation was performed in 1 patient for suspected small-bowel obstruction. There was 1 mortality due to decompensated cirrhosis in the treatment group. This study was limited by its single-institution retrospective design. Full-thickness laparoendoscopic excision is safe and successful compared with corresponding segmental colectomy for complex polyps. Favorable postoperative outcomes, including decreased operative time, length of stay, and blood loss, make it a useful approach for managing complex polyps throughout the colon.

Long-Term Functional Results of a Modified Caudal-to-Cranial Approach in Laparoscopic Segmental Left Colectomy for Diverticular Disease.

A modified caudal-to-cranial approach to perform laparoscopic left colectomy for benign diseases has been recently designed to facilitate the low-tie mesenteric dissection. A chart review has been performed including all consecutive patients with uncomplicated diverticulitis who have been treated by segmental left colectomy with a caudal-to-cranial approach. A total of 34 patients were included in the study. 21 patients were male, mean age was 54.1 ± 11.3, and mean BMI was 26 ± 5.5. Patients with ASA Score I were 7, with ASA II were 9, and with ASA Score III were 5. Incontinence Score (IS) resulted in an average of 5 ± 2, 2 grade of incontinence and the CS score showed an average of 10 ± 3, 2 grade of constipation. Health status, evaluated by Short Form-36 questionnaire, was demonstrated in these patients' great physical function, role, general health, and social function. The anorectal manometry performed 6 months after surgery showed a normal value in terms of the anal resting pressure (47 ± 13 mmHg) and an increased volume to stimulate desire to defecate (197 ± 25 ml). The length of the anal sphincter was normal compared to the reference value (37 ± 5.4 mm). Although further studies are required to obtain definitive conclusions, our results are encouraging to propose low-tie segmental colectomy as the standard procedure for the treatment of uncomplicated diverticulitis, and our modified surgical approach could be considered useful to facilitate the surgical approach.

Short- and long-term outcomes of laparoscopic segmental left colectomy for splenic flexure colon cancer: comparison with propensity score matching.

PurposeSplenic flexure colon cancer (SFCC) is a rare disease that accounts for 2%–8% of colorectal cancers, and the extent of surgery and resection is still debatable. There have also been few studies on the safety and feasibility of laparoscopic surgery for SFCC. The purpose of this study is to evaluate outcomes and prognoses of surgery for SFCC.MethodsWe included patients with stage 1 to 3 who had undergone laparoscopic surgery for distal transverse-to-sigmoid colon cancer at 2 hospitals from March 2004 to December 2016 and collected data by retrospective design. We defined SFCC as being cancer between distal transverse and proximal descending colon. The short- and long-term outcomes of the anterior resection (AR) group (those patients who had undergone laparoscopic AR for mid and distal descending to sigmoid colon cancer) and the left colon resection (LR) group (those who had undergone laparoscopic segmental left colectomy for SFCC) were compared using propensity score matching.ResultsThe median follow-up period was 60 months. The numbers of subjects in the AR and the LR groups were 948 and 118. After 2:1 propensity score matching, 236 vs. 118 patients were selected. There was no significant difference in 5-year disease-free survival (80.7% vs. 78.6%, P = 0.607), and both the 5-year overall survival (89.2% vs. 88.2%, P = 0.563) as well as short-term outcomes showed no statistical difference in most of the variables.ConclusionLaparoscopic segmental left colectomy can be one option among the standard procedures for SFCC.

Laparoscopic-assisted colectomy with Duhamel procedure for idiopathic megacolon in adults: a retrospective study.

Idiopathic megacolon (IMC) is an uncommon disease in adults. To date, only a few laparoscopic experiences and functional outcomes of IMC have been reported. This study was to retrospectively analyse our 12 year surgical experience and functional outcomes in adult patients with IMC. A 12-year retrospective study from October 2006 to November 2018 was performed for patients with IMC who underwent surgical interventions. Patients who underwent laparoscopic-assisted colectomy and Duhamel procedure with ileorectal or colorectal anastomosis were collected. Clinical data of surgery and functional outcomes were analysed. A total of 13 patients who underwent surgical interventions were included in the study. Seven patients underwent laparoscopic total colectomy with ileorectal anastomosis (Duhamel procedure), one patient underwent laparoscopic total colectomy with end ileostomy because of acute intestinal obstruction, while five other patients underwent laparoscopic segmental colectomy with colorectal anastomosis (Duhamel procedure). The mean operative time was 181.6 min (range 150-246). The mean estimated blood loss was 75.6 ml (range 40-200). The mean postoperative hospital stay was 8.2 days (range 6-13). There was no conversion to an open procedure and no surgical mortality. Postoperative diarrhoea was the most prominent complaint during the early period after total colectomy. All patients showed adaptation to the defaecation frequency 3-6 months postoperatively, and had a good quality of life in long-term follow-up. Laparoscopic-assisted colectomy with Duhamel procedure is a safe and efficient technique for IMC in adults. The scope of colon resection and the type of anastomosis should be individually selected.

Laparoscopic-assisted colonoscopic polypectomy: a review

The majority of colon polyps encountered on endoscopy are resected via diathermy snare, which is the most commonly performed therapeutic intervention in colonoscopy. Endoscopic polypectomy can be unsafe when performed on larger polyps or polyps in difficult locations. Polypectomy of these lesions are a risk for perforation, difficulty obtaining clear margins, incomplete sampling due to piecemeal resection, recurrence and histologic misdiagnosis. Such lesions prompt either open or laparoscopic segmental colectomy with inherent risks of major colon resection such as anastomotic leaks and other postoperative complications. Laparoscopic-assisted colonoscopic polypectomy (LACP) is an established alternative to partial colectomy for resection of large, inaccessible, or sessile colon polyps. Laparoscopy facilitates polypectomy by enhancing endoscopic positioning via colonic mobilization and manipulation. This method provides a hybrid technique for resection of benign lesions that complements the strengths of laparoscopy and endoscopy for a minimally invasive surgical technique with good outcomes and low risk. This is a review of the literature regarding the indications, technique, benefits and drawbacks, and postoperative care, and complications of LACP.

Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience.

There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature. Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery.Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1month postoperatively, then every 3months during the first 2years, and every 6months thereafter, for a total of 5years. A total of 28 consecutive patients (16 males) with a median age of 71.8years (range 42.5-88.8years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5%with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively. Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

Alvimopan is associated with decreased length of stay for both open and laparoscopic segmental colectomy

BackgroundAlvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan’s effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. MethodsThe Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. ResultsIn the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). ConclusionAlvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.

C-reactive protein in predicting major postoperative complications are there differences in open and minimally invasive colorectal surgery? Substudy from a randomized clinical trial

BackgroundIn search of improvement of patient assessment in the postoperative phase, C-reactive protein (CRP) is increasingly being studied as an early marker for postoperative complications following major abdominal surgery. Several studies reported an attenuated immune response in minimally invasive surgery, which might affect interpretation of postoperative CRP levels. The aim of the present study was to compare the value of CRP as a predictor for major postoperative complications in patients undergoing open versus laparoscopic colorectal surgery.MethodsA subgroup analysis from a randomized clinical trial (LAFA-trial) was performed, including all patients with non-metastasized colorectal cancer. In the LAFA trial, patients were randomized to open or laparoscopic segmental colectomy. In a subgroup of 79 patients of the LAFA trial, postoperative assessment of CRP levels was conducted routinely preoperatively and 1, 2, 24 and 72 h after surgery.ResultsThirty-seven patients were randomized to the open group and 42 patients to the laparoscopic group. Major complications occurred in 19% of laparoscopic procedures and 13.5% of open procedures (p = 0.776). CRP levels rise following surgical procedures. In uncomplicated cases, the rise in CRP levels was significantly lower at 24 and 72 h following laparoscopic resection in comparison to open resection. No differences in CRP levels were observed when comparing open and laparoscopic resection in patients with major complications.ConclusionIn patients with an uncomplicated postoperative course, CRP levels were lower following minimally invasive resection, possibly due to decreased operative trauma. No differences in CRP were observed stratified for surgical technique in patients with major complications. These results suggest that CRP may be applied as a marker for major postoperative complications in both open and minimally invasive colorectal surgery. Future research should aim to assess the role of standardized postoperative CRP measurements.

Segmental left colectomy: a modified caudal-to-cranial approach.

We have designed a modified caudal-to-cranial approach to perform laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases. IRB approval and informed consent have been obtained. A dissection is conducted to separate the descending mesocolon of the Gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. These maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. The specimen is extracted by a pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to Knight-Griffin technique. We performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. The mean operative time and blood loss were 161.4±15.7min and 50±40ml, respectively. There were not a single conversion to open surgery and no any leakage or stricture. Only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed. We consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall.

Resident training in a teaching hospital: How do attendings teach in the real operative environment?

BackgroundThe study aim was to explore the nature of intraoperative education and its interaction with the environment where surgical education occurs. MethodsVideo and audio recording captured teaching interactions between colorectal surgeons and general surgery residents during laparoscopic segmental colectomies. Cases and collected data were analyzed for teaching behaviors and workflow disruptions. Flow disruptions (FDs) are considered deviations from natural case progression. ResultsAcross 10 cases (20.4 operative hours), attendings spent 11.2 hours (54.7%) teaching, using directing (M = 250.1), and confirming (M = 236.1) most. FDs occurred 410 times, accounting for 4.4 hours of case time (21.57%). Teaching occurred with FD events for 2.4 hours (22.2%), whereas 77.8% of teaching happened outside FD occurrence. Teaching methods shifted from active to passive during FD events to compensate for patient safety. ConclusionsUnderstanding how FDs impact operative learning will inform faculty development in managing interruptions and improve its integration into resident education.

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience.

Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC). All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes. One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45% were laparoscopic-assisted, 32% were hand-assisted, and 8% were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76%), endoscopic staplers (12%), or hybrid techniques (12%). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300min, p=0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12%, p=0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p=0.019). Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.

Tu1756 Laparoscopic Treatment of a Giant Colonic Lipoma Presenting As Transverse Colon Intussusception and Lower Intestinal Bleeding: A Case Report

Introduction: Intussusception in adults accounts for 5% of bowel intussusceptions and of 1% of bowel obstructions. Most adult intussusceptions have a demonstrable lead point. Colonic lipomas are a rare cause of intussusception. They are usually small and asymptomatic, with only 30% reaching more than 2 cm at which point they develop symptoms which include anemia, abdominal pain, constipation, diarrhea, bleeding and intussusception. Giant lipoma has been defined as >5 cm in diameter. We present a case of a 6 cm lipoma in the transverse colon causing gastrointestinal bleeding and colo-colonic intussusception. Case: A 31 year-old male patient presented to the emergency room with a one month history of melena and hematochezia, colicky abdominal pain and in the previous 24 hours nausea, vomiting and abdominal distention. Contrast-enhanced CT scan showed a colo-colonic invagination of transverse colon telescoping into the descending colon (Fig. 1). An enema with hidrosoluble contrast was performed with resolution of the intussusception, and an intraluminal oval pediculated mass of 65x41x37 mm with a density of -21 HU was observed at the splenic angle. Colonoscopy reported a submucosal mass with a blood clot causing obstruction of the bowel lumen 55 cm from the anal verge; its proximal and distal margins were marked with blue dye. The patient was taken to surgery and a laparoscopic segmental transverse colectomy was performed. The histopathological report revealed a 6x5x4 cm submucosal lipoma (Fig. 2). The postoperative evolution was uneventful and the patient was discharged on the fifth postoperative day. Discussion: Colonic lipomas are benign nonepithelial tumors which present most commonly in females within the fifth and sixth decades of life. They are most commonly located in the ascending colon (61%), followed by the descending colon (20%), transverse colon (15%) and rectum (3.4%). Symptoms appear in lipomas >2 cm: anemia, colicky abdominal pain, constipation, bleeding and intussusception. Diagnostic methods include CT scan, contrast-enhanced enema, and colonoscopy. CT scan will reveal a regular, well-delimited spherical or ovoid mass of adipose density (-40 to -120 HU). If associated with intussusception it will show a target lesion, a sausage-shaped mass with layers or a mass caused by edema, mural thickening and vascular compromise. Contrast enhanced enema may aid in the reduction of an intussusception and additionally demonstrate a filling defect. Colonoscopy will reveal a submucosal lesion with three characteristic signs: cushion sign, tenting effect, and naked fat sign. Treatment for symptomatic lipomas includes endoscopic excision or surgical resection, with size being the delimiting factor. Segmental colectomy is the gold standard and may be performed laparoscopically.

Variation of outcome and charges in operative management for diverticulitis.

Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95% CI 1.13-1.55; P<0.05) and Mississippi (OR 2.84; 95% CI 1.24-6.51, P<0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95% CI 0.59-0.94, P<0.01). LOS was 1.4days longer in New York and 0.54days shorter in Wisconsin than in California (P<0.01). Patients with age >40years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.

Additional Procedures Performed During Elective Colon Surgery and Their Adverse Impact on Postoperative Outcomes

BackgroundThe need for additional procedures during a segmental elective colectomy is considered to lead to increased postoperative morbidity, but there have been few data that have validated and quantified this risk. PurposeWe hypothesized that patients having additional procedures performed during a segmental colectomy have worse outcomes compared to patients undergoing a colectomy alone. Patients and MethodsAll patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent an elective open or laparoscopic segmental colectomy during 2005–2009 and met the inclusion criteria were analyzed. Using current procedural terminology (CPT) codes, patients were stratified into three groups. Group 1 only had CPT codes for a colectomy. Group 2 had additional CPT codes for procedures that were considered related to the colectomy, such as splenic flexure mobilization and endoscopy or a relatively minor procedure such as an appendectomy. Group 3 included patients that had additional procedures performed along with a segmental colectomy. Serious morbidity, overall morbidity, return to the operating room, and death were calculated and compared for each group. ResultsThere were 25,996 patients in the open and 20,396 patients in the laparoscopic colectomy group. Thirty-six percent of patients in the open colectomy group vs. 18 % in the laparoscopic colectomy group had additional procedures performed. After adjustment for available differences in the groups, patients undergoing open and laparoscopic segmental colectomy along with an additional procedure had worse postoperative outcomes compared to patients undergoing a colectomy alone. LimitationsThe study is limited by the possibility of coding errors in the ACS NSQIP database leading to a case ascertainment bias and a selection bias given the observational nature of the study. It also could not differentiate between additional procedures that were planned or incidental at the time of surgery. ConclusionsA proportion of patients undergoing elective open and laparoscopic segmental colon resections undergo additional procedures that adversely impact postoperative outcomes. This is mainly related to the type of additional procedures performed and therefore should be accounted for when counseling patients about the risks of surgery and in comparisons of outcomes.

Ureteral stenting in laparoscopic colorectal surgery

BackgroundFew studies have examined the current status of ureteral stent use or the indications for stenting, particularly in laparoscopic colorectal surgery. This study examines current national trends and predictors of ureteral stenting in patients undergoing major colorectal operations and the subsequent effects on perioperative outcomes. MethodsThe 2005–2011 National Surgical Quality Improvement participant user files were used to identify patients undergoing laparoscopic segmental colectomy, low anterior resection, or proctectomy. Trends in stent use were assessed across procedure types. To estimate the predictors of stent utilization, a forward-stepwise logistic regression model was used. A 3:1 nearest neighbor propensity match with subsequent multivariable adjustment was then used to estimate the impact of stents. ResultsA total of 42,311 cases were identified, of which 1795 (4.2%) underwent ureteral stent placement. Predictors of stent utilization included diverticular disease, need for radical resection (versus segmental colectomy), recent radiotherapy, and more recent calendar year. After adjustment, ureteral stenting appeared to be associated with a small increase in median operative time (44 min) and a trivial increase in length of stay (5.4%, P < 0.001). However, there were no significant differences in morbidity or mortality. ConclusionsWe describe the clinical predictors of ureteral stent usage in this patient population and report that while stenting adds to operative time, it is not associated with significantly increased morbidity or mortality after adjusting for diagnosis and comorbidities. Focused institutional studies are necessary in the future to address the utility of ureteral stents in the identification and possible prevention of iatrogenic injury.