Emergency Laparoscopic-Assisted Right Hemicolectomy: Can We Achieve Outcomes Similar to Elective Operation?

Abstract

The aim of this study was to compare short-term clinical outcomes of elective and emergency laparoscopic-assisted right hemicolectomy. Between January 2005 and December 2009, 181 patients had laparoscopic-assisted right hemicolectomy performed at our institute (148 elective and 33 emergency cases). The demographic data, operative details, and short-term outcomes were collected. There were 104 men and 77 women. The median age was 69 years (range, 22–88 years). The demographic data of the 2 groups were similar except the patients were younger in the emergency surgery group (60 vs. 69 years; P=.02). The operating time of the emergency group was significantly longer then the elective group (165 vs. 150 minutes; P<.001) but the intraoperative blood loss was similar. The postoperative complication and recovery were similar between the 2 groups. In selected clinical settings, emergency laparoscopic-assisted right hemicolectomy can be safely performed without worsening the clinical outcomes.

Introduction

With the advances in surgical skills and technology, laparoscopic colorectal surgery has rapidly developed in the past decade. Laparoscopic colectomy is a widely accepted treatment for elective management of benign and malignant colonic disease. Studies on medium- and long-term oncologic outcomes showed that laparoscopic resection does not compromise the cure of patients with colorectal malignancy.^1–5 However, laparoscopic colectomy in emergency setting is not widely practiced, and in fact, the feasibility and outcome of emergency laparoscopic colectomy has as not been yet fully studied.

Traditionally, in emergency conditions, laparoscopic colectomy has been considered relatively contraindicated. So far there has been little data regarding laparoscopic colectomy in the emergency setting, and its benefits have not been properly evaluated. We have previously reported that emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma⁶ and cecal diverticulitis⁷ is feasible and safe in the hands of experienced laparoscopic surgeons. Compared with open approach, laparoscopic-assisted approach is associated with less blood loss, shorter time to first bowel motion, earlier ambulation, and possibly lower morbidity rate.^6,7

This study aimed to investigate the impact of laparoscopic-assisted right hemicolectomy on the outcome of emergency right colon pathologies. The results of the patients with emergency and elective laparoscopic-assisted right hemicolectomy were compared, with special attention to operative time, blood loss, conversion rate, short-term outcomes, and complications.

Materials and Methods

From January 2005 to December 2009, 293 patients who had right colon resection (209 elective and 84 emergency) were identified from our colorectal surgery database. During this period, 181 patients who had laparoscopic-assisted right hemicolectomy were included in this study. The data were prospectively collected and retrieved from our colorectal surgery database.

The patients were divided into 2 groups: those with emergency (n=33) and those with elective laparoscopic-assisted right hemicolectomy (n=148). The indication of surgery and demographic data of the 2 groups were compared. The outcomes of surgery for the 2 groups were also compared with respect to operative time, blood loss, conversion rate, lymph node harvest, blood transfusion, analgesic usage, time to return of bowel function, resumption of diet, complications, wound length, and hospital stay.

For the emergency group, no patient received a preoperative bowel preparation. The decisions of performing right hemicolectomy laparoscopically were made either preoperatively according to the clinical conditions (including obstructing carcinoma of right colon or complicated ileocecal Crohn's disease) or intraoperatively according to laparoscopy findings (right colon diseases required right hemicolecotmy). Exclusion criteria included that (1) patients with general peritonitis or grossly distend abdomen make laparoscopic colectomy unsafe or (2) surgeons with experience on laparoscopic colectomy are not available.

Our techniques for elective and emergency laparoscopic-assisted right hemicolectomy have been previously reported.^6,8 In principle, we mobilized the right-sided colon from the terminal ileum to the transverse colon. The lymphovascular pedicles were intracorporeally transected. A port wound was extended to deliver the specimen under the protection of a plastic bag. The division of the remaining mesentery, the marginal artery, and the bowel were extracorporeally done. The ileocolic anastomosis was extracorporeally performed, either handsewn or with two linear staplers (functional end-to-end anastomosis). Postoperatively, diet was resumed as soon as bowel function returned clinically (as indicated by positive bowel sound and passage of flatus). Patients were discharged when they tolerated diet and were fully ambulatory. Clinical data including operative details and immediate clinical outcomes were prospectively collected in our colorectal database and compared between the emergency and elective surgery groups. Tumor staging reported in this study was based on the 6th edition of the American Joint Committee on Cancer manual.⁹

Statistical analysis was performed with Statistical Package for Social Science version 14.0 for Windows (SPSS, Inc., Chicago, IL). Chi-squared test (or Fisher's exact test) was used to compare categorical data and the Mann–Whitney U test was used to compare continuous data; P value of .05 or less was considered statistically significant.

Results

The median age of patients who had laparoscopic right colon resection was 69 years (range, 22–88 years). Emergency laparoscopic-assisted right hemicolectomy was performed in 33 patients and elective laparoscopic-assisted right hemicolectomy was performed in 148 patients. The indications for surgery are shown in Table 1. The most common indications for emergency laparoscopic right hemicolectomy were obstructing right colon cancer (n=19) and complicated cecal diverticulitis (n=7). The median time of surgery from admission is 1 day (range, 0–3 days).

Table 1.

Indication for Surgery

	Emergency surgery group (n=33)	Elective surgery group (n=148)
Cancer	19	128^a
Polyps	0	13
Diverticulitis	7	0
Inflammatory bowel disease	2	2
Others	5^b	5^c

One patient had lymphoma.

One patient had intussusception, 1 patient had infected right colon inclusion cyst, 2 patients had appendicular mass with abscess formation, and 1 patient had leaking stump post-appendectomy.

Four patients had cecal mass and 1 patient had mucocele of appendix.

The patients in the emergency surgery group were significantly younger than the patients in the elective surgery group (60 vs. 69 years; P=.02). The other demographic data of the 2 groups were comparable (Table 2).

Table 2.

Demographic Data

	Emergency surgery group (n=33)	Elective surgery group (n=148)	P value
Age, years^a	60 (22–87)	69 (25–88)	.02^b
Male/female	20/13	84/64	.69^c
ASA≤2/ASA >3	28/5	119/29	.56^c
AJCC staging (I/II/III/IV)	1/9/3/6	14/61/31/20	.34^c
Previous operation (%)	7 (21.2)	35 (23.6)	.76^c

Data are expressed as median (range).

Mann–Whitney U test.

Chi-square test or Fisher's exact test.

ASA, American Society of Anesthesiologists; AJCC, American Joint Committee on Cancer.

The median operative time was significantly longer in the emergency surgery group (165 vs. 150 minutes, P<.001) than in the elective surgery group. However, operative blood loss, blood transfusion, conversion rate, wound length, and number of lymph nodes removed were not significantly different between the 2 groups (Table 3).

Table 3.

Operative Details

	Emergency surgery group (n=33)	Elective surgery group (n=148)	P value
Anastomosis: handsewn/stapled	8/25	29/118^a	.56^b
Extended right hemicolectomy/right hemicolectomy	5/28	38/110	.20^b
Conversion, n (%)	0	1 (0.7)	1.0^b
Operative time, minutes^c	165 (106–350)	150 (80–340)	<.001^d
Blood loss, mL^c	30 (0–500)	20 (0–1500)	.17^d
Blood transfusion	1	2	.46^b
Incision length, cm^c	8 (6–9)	7.5 (5–12)	.72^d
Number of lymph node removed^c	17 (11–36)	18 (6–53)	.57^d

One patient had no primary anastomosis.

Chi-square test or Fisher's exact test.

Data are expressed as median (range).

Mann–Whitney U test.

The conversion rate of this study was 0.55% (1 patient in the elective surgery group and none in the emergency surgery group). The reason for conversion was locally advanced tumor. Primary anastomosis was performed in all but 1 patient.

The immediate clinical outcomes of surgery in terms of analgesic usage, resumption of soft diet, time to flatus, and time to bowel movement were similar between the 2 groups. The time to full ambulation and the duration of hospital stay were also not different between the 2 groups (Table 4). Performing laparoscopic right hemicolectomy in an emergency setting did not result in prolonged recovery of patients when compared with the elective counterpart.

Table 4.

Immediate Clinical Outcomes

	Emergency surgery group (n=33)	Elective surgery group (n=148)	P value
Dose of parenteral analgesia	4 (0–24)	3 (0–50)	.92^a
Time to resumption of soft diet, days	5 (3–13)	5 (3–15)	.61^a
Time to first flatus, days	3 (1–6)	3 (1–15)	.67^a
Time to first bowel movement, days	5 (2–11)	4 (2–17)	.46^a
Time to full ambulation, days	4 (1–8)	4 (1–18)	.36^a
Hospital stay, days	8 (6–43)	8 (5–29)	.47^a

All data are expressed as median (range).

Mann–Whitney U test.

Table 5 shows the postoperative complications. Complications occurred in 53 patients, contributing to an overall operative morbidity rate of 29.3%. There were 11 patients (33.3%) in the emergency surgery group and 42 patients (28.4%) in the elective surgery group who suffered from postoperative complications. The overall and specific complication rates were similar in the 2 groups; wound infection was the most common complication, which amounted to 12.1% in emergency surgery group and 5.4% in elective surgery group, and was not significantly different between the 2 groups. Four patients required reoperation in the elective surgery group, 2 patients had intestinal obstruction and required adhesiolysis, and 2 patients had anastomotic leak. Two patients required reoperation in the emergency surgery group; the reasons were infected hematoma and acute cholecystitis. There was no anastomoic leak in the emergency surgery group. One patient in the emergency surgery group died 19 days after the operation because of acute coronary syndrome.

Table 5.

Postoperative Complications

	Emergency surgery group (n=33)	Elective surgery group (n=148)	P value
Wound infection	4	8	.24^a
Chest infection	1	5	1.0^a
Urinary tract infection	3	13	1.0^a
Retention of urine	0	7	.35^a
Fever	1	3	.57^a
Anastomotic leakage	0	2	1.0^a
Reoperation, n (%)	2	4	.30^a
Operative mortality, n (%)	1	0	.18^a
Number of patient with complications, n (%)	11 (33.3)	42 (28.4)	.57^b

Fisher's exact test.

Chi-square test.

Discussion

There were some reports on emergency laparoscopic colectomy in acute colitis, diverticulitis, and obstructing colon cancer.^6,7,10–12 Franklin et al.¹³ reported the use of laparoscopy in 167 patients with intestinal obstruction; 23 patients were found to have obstructing colon carcinoma and underwent laparoscopic resection. Gonzalez et al.¹⁰ reported 21 patients with emergency laparoscopic palliative procedures for complicated colorectal carcinoma and 5 of them had right hemicolectomy performed. We had previously reported the use of laparoscopic-assisted right colectomy for obstructing carcinoma of colon⁶ and complicated cecal diverticulitis⁷; compared with open surgery, the operative outcomes were not inferior to that of open surgery. According to the results of the aforementioned studies, laparoscopic-assisted right hemicolectomy is feasible in emergency conditions. However, literature on direct comparison of the results of elective and emergency settings is scarce, making the real potential benefits for emergency laparoscopic colorectal procedure uncertain.

In our study, the outcomes of elective and emergency surgery were compared and there was little difference except patients' age and operative time. The difference in age may be due to the fact that younger patients tend to have more benign disease present in an acute setting. The operative time of the emergency surgery group is significantly longer than that of the elective surgery group, which may be related to the increased difficulty in the emergency setting.

The satisfactory outcome of our series reflects the importance of case selection. In the emergency right hemicolectomy group, we had patients suffering from various right colon pathologies including obstructing cancer of colon, complicated diverticulitis, complicatied ileo-cecal Crohn's disease, and right colon masses. Obviously, laparoscopic approach cannot be practically applied to every patient who requires emergency right hemicolectomy. Patients with colonic perforation, severe contamination, extensive abdominal adhesion, large tumor, or high-grade obstruction are generally not good candidates for emergency laparoscopic surgery. Although case selection is an individual surgeon's decision and we have no strict selection criteria for emergency laparoscopic colectomy, the points stated above are in fact the general consensus of our team. Appropriate case selection is the key to avoid prolonged operation, excessive conversion to open surgery, and complicated postoperative course. Selection bias was inevitable in this study, and a randomized study is difficult to conduct in real-life practice.

Performing emergency laparoscopic colectomy can be very difficult and technically demanding. The difficulty can be due to limited exposure as a result of dilated bowel. Additionally, the friable inflamed tissue makes handling very difficult, and the bleeding during dissection can further obscure the view. Therefore, laparoscopic colectomy in particular emergency cases should be attempted only by surgeons who are well trained in laparoscopic techniques and experienced in complicated laparoscopic operations. Our previous study confirmed that conversion was associated with increase morbidity. We observed that operations performed in an earlier time period (before year 2002) was an independent factor associated with open conversion.¹⁴ With evolution and refinement in surgical skills, the conversion rate of our institution in the study period was low. In our study, all resections were technically feasible even in the presence of moderate bowel distention or localized contamination, and all patients received definitive laparoscopic resections. All the operations were carried out by colorectal specialists who were fully competent in advanced laparoscopic surgery. Surgical specialization has been shown to have a positive impact on the outcome of both elective and emergency colorectal surgeries.^15,16 With increasing availability of experienced laparoscopic surgeons, emergency laparoscopic-assisted right colectomy can be safely performed in carefully selected patients with acute right colon pathologies.

In conclusion, our results demonstrated that emergency laparoscopic-assisted right hemicolectomy can be performed safely with outcomes approximate to those of standard elective laparoscopic approach. The keys to success of this complicated procedure are appropriate patient selection and the presence of experienced laparoscopic surgeons.

Footnotes

Disclosure Statement

No competing financial interests exist.

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