Laparoscopic vs Open Colorectal Surgeries in Urgent Surgical Situations

INTRODUCTION

Minimally invasive surgeries (MISs) have become the preferred surgical approach for performing elective resections of the colon and rectum.¹ Minimally invasive surgeries have many clear benefits as less postoperative pain and ileus, short hospital length of stay (LOS), and better quality of life in addition to similar oncologic outcomes.² These advantages made MISs the approaches of choice by most surgeons for performing nearly 50% of elective colorectal resections.³

Using MISs in non-elective and urgent cases was assessed by many previous studies and found by most of them to be nearly similar to and even better than open surgeries.^4,5 Minimally invasive surgeries in urgent cases was found to be associated with; reduced costs, short LOS, and less postoperative morbidity and mortality than open colectomy.⁶

These former studies include both urgent and emergency colorectal resections and using MISs was reported in 5–30% of all cases.^7,8

There was no sufficient data regarding long-term, follow-up, tumor recurrence, or survival data of studied patients in those studies.

Aim of our study is to compare performing MIS and open colectomy in patients undergoing urgent (nonemergency, non-elective) colectomies, regarding primary outcomes of 30-day morbidity and mortality, secondary short-term outcomes, long-term and follow-up findings of included patients.

PATIENTS AND METHODS

This is a retrospective randomized study that was approved by the Institutional Review Board of the Faculty of Medicine, Zagazig University. We included all colectomies performed between January 1, 2016, and December, 2021.

After the application of inclusion criteria of selecting patients with non-elective colectomy and excluding all cases with elective planned colectomy and cases with incomplete data, 200 patients were included, and we divided them into two groups according to the performed surgical approach: The first group included 100 patients who underwent MISs and the second group underwent open surgery and included 100 patients.

Minimally invasive surgery patients included: Totally laparoscopic surgery, laparoscopic surgery with open assistance, and laparoscopic surgery with unplanned conversion to open surgery.

The group of patients who underwent open surgeries included all patients with planned urgent open colectomies.

We compared between both groups of patients as regards; baseline demographic data and comorbidities.

We evaluated the primary patients’ outcome which was 30-day postoperative morbidity and mortality. Secondary evaluated patients’ outcomes included; ICU admissions, surgical reintervention, hospital LOS, wound infection or dehiscence, postoperative ileus, postoperative leakage at anastomotic site, occurrence of intra-abdominal infections, and pulmonary or cardiac complications.

Long-term evaluated patients’ outcomes included the occurrence of incisional hernias and oncological outcomes as overall survival rates and recurrence rates.

RESULTS

This study included 200 patients with an age range from 30 to 68 years with a mean age of 50.51 years and a mean BMI of 22.54 kg/m². Males represented 33% of them. Patients of 135 underwent histopathological examination; of them, 51.1% had conventional adenocarcinoma, 21.5% had benign lesions. Among 106 patients with confirmed malignancy by HPE; 29.2, 28.3, and 23.6% had T stage 4, 3, and 1, respectively. concerning N stage; 65.1% had stage 0, 16% had N stage 3 with no patient with distant metastasis. About 50, 29.2, and 20.8% had grades II, III, and I, respectively.

On investigating the cause of resection, 53, 14.5, and 10% underwent resection for malignancy, benign neoplasm, and ischemia respectively. About 37, 25, and 23% underwent right hemicolectomy, sigmoid resection, and anterior resection respectively.

Of patients, 56.5% underwent an open approach while the remaining 45.5% had a laparoscopic approach.

Among the MIS group of patients (20%) underwent unplanned conversion to open.

Regarding demographic and baseline data, patients who underwent open surgery were older (65 years vs 58 years, p < 0.001). More females underwent open surgery (54 vs 50%, p = 0.002).

Overweight and obese patients were more likely to have MIS colectomy (p < 0. 001).

American Society of Anethesiologists (ASA) I and II patients were more likely to have MIS in comparison with ASA III patients (p < 0.001). Patients with comorbid conditions were more likely to have open surgery (p < 0.001).

Minimally invasive surgery patients were more likely to have completed mechanical and antibiotic bowel preparation (p < 0.001).

Generally, the commonest surgery indications were obstructing or perforating colorectal cancer and acute diverticulitis.

There is statistically significant relation between approach and all of sex (79.3% within laparoscopic approach vs 57.5% within open approach were females), reason for resection (66.7% within laparoscopic approach vs 42.5% within open approach underwent resection for malignancy), ASA classification (20.7% within laparoscopic approach vs 58.4% within open approach had ASA I), and type of primary operation (2.3% within laparoscopic approach vs 12.4% within open approach underwent anterior resection).

There is a statistically non-significant relation between the approach and either age, BMI, or resection site (Table 1).

There is a statistically significant relation between approach and all histopathological types (24.2% within the laparoscopic approach vs 11.6% within the open approach had mucoid carcinoma), N stage (82.8% within the laparoscopic approach vs 43.8% within the open approach had N stage 0), American Joint Committee on Cancer (AJCC) stage (63.8% within laparoscopic approach vs 20.8% within open approach had AJCC stage II).

There is statistically non-significant relation between approach and either T stage, M stage, or grade.

Minimally invasive surgery colectomy patients were liable to be diagnosed with obstructing or perforating colorectal cancer, chronic diverticulitis with stricture, ulcerative colitis, or bleeding colorectal polyps.

Open colectomy was liable to be diagnosed with acute diverticulitis and volvulus (p < 0.001). Operative time is longer in MIS patients in comparison to open colectomy patients the median time to complete an MIS colectomy was 21 minutes longer (p < 0.001).

Postoperative mortality is less in MIS patients than in open surgery patients.

On univariable analysis, 30-day postoperative mortality following MIS colectomy was lower than that after open surgery (p < 0.05).

Prolonged duration of staying in hospital (>30 days), postoperative bleeding, shock, sepsis, postoperative ileus, reoperation, dehiscence or infection of the wounds, anastomotic leakage, deep venous thrombosis (DVT), urinary tract infection (UTI), surgical site infections (SSI), pulmonary embolism (PE), and hospital readmission were lower for the MIS patients.

Minimally invasive surgery patients had a shorter duration of hospital stay (p < 0.001).

Regarding long-term incidence of incisional hernias is less in the MIS group of patients (Table 2).

There is a statistically significant relation between approach and short-term complications. The open approach significantly increases the risk of short-term complications by 2.2 folds.

There is a statistically non-significant relation between approach and either reoperation or long-term complications. The open approach significantly increases the risk of reoperation and long-term complications by 1.8 and 1.46 folds respectively (Table 3).

There is a statistically significant relation between complications and all of sex (50% within complicated vs 26.4% of non-complicated were males), and approach (32.1% within complicated vs 47.9% within non-complicated underwent laparoscopic approach).

There is a statistically non-significant relation between approach and either age, resection site, type of operation, BMI, or ASA classification.

Regarding long-term oncological outcomes such as tumor recurrence, response to therapy, and 3-year overall survival rate and 3-year recurrence-free survival rate, there were no significant differences between performed surgical approaches (Table 4).

DISCUSSION

In the present study, we clarified the advantages of MIS in urgent colectomy cases over open surgery and demonstrated their benefits over open colectomy regarding postoperative short-term outcomes, long-term outcome, our findings are similar to the results of Hajirawala et al.,⁸ study and Warps et al.,⁹ who showed that MIS is beneficial in non-elective cases of colectomy. Minimally invasive surgery in urgent colectomy was associated with lower; mortality, short hospitalization, less incidence of ileus, less wound infection or dehiscence, and less readmission rate (Tables 5 and 6).

Minimally invasive surgery was demonstrated to be better than open surgery by many previous studies.^4,5,10

Vallance et al.,⁶ showed similar results to ours that MIS was associated with a shorter duration of hospital stay and less incidence of 90-day mortality than open colectomy.

Moreover, Keller et al.,⁷ demonstrated that MIS was associated with favorable short-term and long-term outcomes. Post-colectomy wound infections particularly in urgent non-elective cases are liable to occur, and it was found that MIS was associated with lower incidence than open cases.¹¹

Postoperative readmissions after colectomy were associated with increased postoperative morbidity, mortality, and reduced overall survival rate.¹²

We showed similar to previous reports that patients who underwent urgent MIS colectomy were less liable to hospital re-admission this is due to a reduction in rates of most short-term postoperative complications following MIS.

Patients who underwent MIS colectomy were less likely to have hypertension, chronic obstructive pulmonary disease, renal failure, dialysis, smoking, sepsis at the time of surgery.

Patients with comorbid conditions were more liable to perform open surgery, which is in line with previous reports.^6,7

Former studies showed that MIS in patients undergoing colectomies has less liability to short-term morbidity and mortality.^8,13

CONCLUSIONS

We demonstrate that using MIS in urgent colectomy is associated with less postoperative, morbidity, mortality, less short-term complications, and long-term complications than open colectomy.

REFERENCES

1. Hajirawala LN, Krishnan V, Leonardi C, et al. Minimally invasive surgery is associated with improved outcomes following urgent inpatient colectomy. JSLS 2022;26(1):e2021.00075 1. DOI: 10.4293/JSLS.2021.00075.

2. Govaert JA, Fiocco M, van Dijk WA, et al. Dutch value based healthcare study group. multicenter stratified comparison of hospital costs between laparoscopic and open colorectal cancer resections: influence of tumor location and operative risk. Ann Surg 2017;266(6):1021–1028. DOI: 10.1097/SLA.0000000000002000.

3. Davis CH, Shirkey BA, Moore LW, et al. Trends in laparoscopic colorectal surgery over time from 2005–2014 using the NSQIP database. J Surg Res 2018;22316–21. DOI: 10.1016/j.jss.2017.09.046.

4. Nash GM, Bleier J, Milsom JW, et al. Minimally invasive surgery is safe and effective for urgent and emergent colectomy. Colorectal Dis 2010;12(5):480–484. DOI: 10.1111/j.1463-1318.2009.01843.x.

5. Catani M, De Milito R, Romagnoli F, et al. Laparoscopic colorectal surgery in urgent and emergent settings. Surg Laparosc Endosc Percutan Tech 2011;21(5): 340–343. DOI: 10.1097/SLE.0b013e3182318b5c.

6. Vallance AE, Keller DS, Hill J, et al. Role of emergency laparoscopic colectomy for colorectal cancer. Ann Surg 2019;270(1):172–179. DOI: 10.1097/SLA.0000000000002752.

7. Keller DS, Pedraza R, Flores-Gonzalez JR, et al. The current status of emergent laparoscopic colectomy: A population-based study of clinical and financial outcomes. Surg Endosc 2016;30(8):3321–3326. DOI: 10.1007/s00464-015-4605-z.

8. Hajirawala L, Leonardi C, Orangio G, et al. Urgent inpatient colectomy carries a higher morbidity and mortality than elective surgery. J Surg Res 2021;268394–404. DOI: 10.1016/j.jss.2021.06.081.

9. Warps AK, Zwanenburg ES, Dekker JWT, et al. Laparoscopic versus open colorectal surgery in the emergency setting a systematic review and meta-analysis. Ann Surg Open 2021;2(3):e097. DOI: 10.1097/AS9.0000000000000097.

10. Champagne B, Stulberg JJ, Fan Z, et al. The feasibility of laparoscopic colectomy in urgent and emergent settings. Surg Endosc 2009;23(8):1791–1796. DOI: 10.1007/s00464-008-0227-z.

11. Gantz O, Zagadailov P, Merchant AM. The cost of surgical site infections after colorectal surgery in the United States from 2001 to 2012: A longitudinal analysis. Am Surg 2019;85(2):142–149. PMID: 30819289.

12. Schneider EB, Hyder O, Brooke BS, et al. Patient readmission and mortality after colorectal surgery for colon cancer: Impact of length of stay relative to other clinical factors. J Am Coll Surg 2012;214(4):390–398. DOI: 10.1016/j.jamcollsurg.2011.12.025.

13. Mullen MG, Michaels AD, Mehaffey JH, et al. Risk associated with complications and mortality after urgent surgery vs elective and emergency surgery. JAMA Surg 2017;152(8):768–774. DOI: 10.1001/jamasurg.2017.0918.