Surg Today DOI 10.1007/s00595-015-1157-8

ORIGINAL ARTICLE

Laparoscopic right colectomy in patients treated with previous gastrectomy Atsushi Ikeda1 · Yosuke Fukunaga1 · Takashi Akiyoshi1 · Tsuyoshi Konishi1 · Yoshiya Fujimoto1 · Satoshi Nagayama1 · Masashi Ueno1 

Received: 1 December 2014 / Accepted: 24 February 2015 © Springer Japan 2015

Abstract  Purpose  Laparoscopic colorectal surgery is increasingly being performed in patients treated with previous abdominal surgery. This is a retrospective study designed to evaluate the feasibility of laparoscopic right colectomy in patients with a previous history of gastrectomy. Methods  Of 838 consecutive patients who underwent elective laparoscopic right colectomy, 23 had previously undergone gastrectomy (PG group) and 516 had no history of previous abdominal surgery (NS group). The short-term surgical outcomes were retrospectively investigated in the PG and NS groups. Results  The median patient age was 75 years in the PG group and 67 years in the NS group (p  = 0.0026), and the median body mass index in both groups was 19.2 and 22.6 kg/m2, respectively (p  = 0.0006). The mean operative time, amount of blood loss and postoperative hospital stay were similar. One patient in the PG group and five patients in the NS group required conversion to laparotomy (p = 0.1307). Three patients in the PG group experienced postoperative complications, one each with an intraperitoneal abscess, wound infection and enterocolitis; however, none of these complications were directly attributable to adhesiolysis. The rates of intraoperative and postoperative complications were similar. Conclusions  Laparoscopic right colectomy is feasible in patients treated with previous gastrectomy.

* Yosuke Fukunaga [email protected] 1



Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3‑8‑31 Ariake, Koto‑ku, Tokyo 135‑8550, Japan

Keywords  Laparoscopic surgery · Right colectomy · Previous surgery · Gastrectomy · Complication

Introduction Following the initial report on laparoscopic segmental colectomy in 1991 [1], the use of laparoscopy to remove colorectal malignancies has steadily increased. Randomized controlled studies have demonstrated the safety and oncologic efficacy of laparoscopic colon surgery, making it a standard approach in patients with colon cancer [2–5]. Although previous abdominal surgery (PAS) was initially regarded as a contraindication for laparoscopy, studies have found that cholecystectomy [6, 7] and urologic procedures [8] are safe in patients who have undergone PAS. To date, however, laparoscopic and open colorectal procedures have not been compared in patients treated with PAS. Recent studies have reported that PAS does not affect the short-term outcomes of laparoscopic colorectal surgery [9–11]; however, these studies addressed the outcomes of all types of laparoscopic colorectal operations following various types of PAS. In addition, the effects of PAS on colectomy outcomes at the same site have not been addressed. In order to assess the actual impact of PAS on subsequent colectomy, we focused on patients undergoing right colectomy with a history of previous gastrectomy, as one of the major abdominal surgeries that might possibly have an effect on subsequent colectomy performed in the same operative field. To our knowledge, this is the first study designed to investigate the impact of previous gastrectomy on laparoscopic right colectomy.

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Surg Today

Methods

Statistical analysis

Patient selection and data collection

Differences between the groups were analyzed using the χ2 test, Fisher’s exact test or Mann–Whitney U test, as appropriate. All statistical analyses were performed using the JMP9.0 software program (SAS Institute Inc., Cary, NC, USA), with a p value less than 0.05 considered to be statistically significant.

We reviewed the medical records of 667 consecutive patients who underwent elective laparoscopic right colon surgery for primary right colon cancer between July 2004 and November 2013 at the Cancer Institute Hospital, Tokyo, Japan. Patients with recurrent disease and those who required emergency surgery were excluded. Of the 667 patients, 23 had previously undergone gastrectomy (PG group), whereas 516 had no history of PAS (NS group). The remaining patients were excluded, because either they underwent synchronous major surgery (n  = 46) or they had undergone a PAS procedure other than gastrectomy (n = 172). The only contraindication to laparoscopic surgery for right colon cancer was massive invasion of the adjacent organs, such as the pancreas or duodenum. All laparoscopic colorectal procedures were performed by six expert colorectal surgeons, each of whom had performed over 500 such operations and had a certification for endoscopic surgery from the Japan Society for Endoscopic Surgery. The patients’ demographic data were collected from their medical records, including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score and presence of comorbidities. Investigated surgical outcomes included the operative time, amount of blood loss, previous number of laparoscopic surgical procedures, conversion to laparotomy, time to flatus, intraoperative and postoperative complications and postoperative hospital stay. Intestinal injury requiring conversion to laparotomy and massive bleeding of >300 ml was regarded as an intraoperative complication. Conversion to laparotomy was defined as the creation of an unplanned incision. None of the patients required conversion to a hand-assisted procedure. The surgical procedures were categorized as ileocecal resection (ICR), right hemi-colectomy and transverse colectomy. ICR was defined as a procedure requiring division of the ileocolic artery with surrounding lymphadenectomy. Right hemi-colectomy was defined as a procedure requiring division of the ileocolic artery, right colic artery (when present) and right branch of the middle colic artery with surrounding lymphadenectomy. Transverse colectomy was defined as a procedure requiring division of the middle colic artery with surrounding lymphadenectomy [12]. A four- or five-port technique was used. Reconstruction was performed extracorporeally using functional end-to-end anastomosis or the triangulating stapling technique [13]. No drainage tubes were left inside the peritoneum.

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Results Table  1 shows the profiles of the 23 patients in the PG group. Of the 23 patients, 22 had undergone previous surgery for gastric cancer and one for duodenal ulcer; these operations included total gastrectomy in three patients, distal gastrectomy in 19 patients and a partial resection of the stomach in one patient. The most frequent reconstruction method was Billroth-I, followed by the Roux-en-Y technique. Twenty patients had undergone open surgery, and two had undergone laparoscopic surgery. The demographic characteristics of the patients in the two groups are summarized in Table 2. The median age was significantly higher, and the median BMI was significantly lower in the PG than in the NS group. There were no significant between-group differences in the distribution of the pathological stage or ASA score. The surgical outcomes are shown in Table 3. Of the 23 PG patients, 10 underwent right hemi-colectomy, nine Table 1  Profiles of the previous gastrectomy patients in the PG group n (%) Gastric cancer  +  – Procedure  Total gastrectomy  Distal gastrectomy  Partial gastrectomy Fashion of reconstruction  Billroth-I  Billroth-II  Roux-en-Y  Simple closure Type of approach  Laparotomy  Laparoscopy  Robotic surgery

22 (95.7 %) 1 (4.3 %) 3 (13.0 %) 19 (82.6 %) 1 (4.3 %) 13 (56.5 %) 1 (4.3 %) 8 (34.8 %) 1 (4.3 %) 20 (87.0 %) 2 (8.7 %) 1 (4.3 %)

The percentages in this column may not add up to exactly 100 % because of rounding

Surg Today Table 4  Surgical outcomes in the PG group

Table 2  Demographic characteristics PG group (n = 23) NS group (n = 516)

Sex ratio (male:female) Mean age (range) Mean body mass index (kg/m2) ASAa score  I  II  III Pathological stage  0 or adenoma  I  II  III  IV  Other disease

Number (%)

Number (%)

8:15

270:246

0.0995

75 (38–93)

67 (31–90)

0.0026

19.2 (15.4–26.1)

22.6 (14.2–36.0)

0.0006

3 (13.0) 18 (78.3) 2 (8.7)

168 (32.6) 339 (65.7) 9 (1.7)

0.0151

6 (26.1) 5 (21.7) 6 (26.1) 5 (21.7) 1 (4.3)

57 (11.0) 148 (28.7) 141 (27.3) 125 (24.2) 37 (7.2)

0.3793

0 (0.0)

8 (1.6)

  American Society of Anesthesiologists

Table 3  Surgical outcomes NS group (n = 516)

Number (%)

Number (%)

Laparoscopic colorectal procedure  Ileocecal resection 9 (39.1) 204 (39.5)  Right hemi-colectomy 10 (43.4) 266 (51.6)  Transverse colectomy 4 (17.4) 46 (8.9) 217 (104–324) 199 (65–400) Operating time (min)a 10 (5–200) 15 (0–555) Blood loss (ml)a Conversion to laparotomy 1 (4.3) 5 (1.0) 2 (1–3) 2 (0–4) Postoperative time to flatus (day)a Postoperative hospital stay (day)a

10 (8–56)

10 (5–53)

Operating time (min)a Blood loss (ml)a Postoperative hospital stay (day)a

p value

Done (n = 13)

Not done (n = 10)

221 (179–324) 20 (7–200)

153 (104–247) 10 (5–40)

10 (8–56)

11 (8–13)

0.0100 0.0261 0.9002

MCA Middle colic artery a

  Median (range)

a

PG group (n = 23)

Lymphadenectomy around the MCA and gastrocolic trunk

p value

p value

was significantly longer and blood loss was significantly greater in the patients who underwent lymphadenectomy (Table  4). Lymphadenectomy around these vessels was performed meticulously and precisely in all patients in this series (Fig. 1). Table  5 summarizes the surgical complications in the two groups. Massive bleeding was observed in 12 patients in the NS group, compared to none of the patients in the PG group. One patient in the NS group, but none of the patients in the PG group, experienced intestinal injury requiring conversion to laparotomy. The postoperative complication rates were similar in the two groups.

Discussion 0.3704

0.5664 0.8722 0.1307 0.9590 0.2485

a

  Median (range)

underwent ileocecal resection and four underwent transverse colectomy. None of the variables differed significantly, including the type of laparoscopic procedure, mean operative time, mean amount of blood loss, open conversion rate, time to flatus and postoperative hospital stay. One patient (4.4 %) in the PG group and five patients (0.97 %) in the NS group required conversion to open surgery. When the PG group was subdivided into patients who did and did not require lymphadenectomy around the middle colic artery and the surgical trunk, the operative time

Intraperitoneal adhesion develops after abdominal surgery [14] and must be freed during subsequent surgery to access the target organs, thus increasing the operative time and perioperative complication rates [15, 16]. Inadvertent intestinal injury is a serious complication in patients undergoing reoperation. For example, enterotomy occurred during 51 of 270 (19 %) abdominal reoperations, with these patients having higher rates of postoperative complications and admission to the intensive care unit as well as a longer postoperative hospital stay than patients treated without enterotomy [17]. The presence of intra-abdominal adhesion is associated with several specific problems during laparoscopic reoperation. These include increased risks of bowel and vascular injury during insertion of the trocar and inadvertent intestinal injury because of limitations in visualization and the lack of tactile sensation. Adhesion may also distort the normal anatomy, the making the achievement of sufficient visualization more difficult. Hence, PAS is regarded as a relative contraindication for laparoscopy. Several studies have analyzed the impact of PAS on laparoscopic colorectal surgery. One study involving almost 300 patients who underwent laparoscopic colorectal

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Surg Today Table 5  Surgical complications Complications

Fig.  1  a Lymph node dissection at the origin of the vessels in right hemi-colectomy. b Illustration of the same situation. St stomach, Du duodenum, TC transverse colon, Pa pancreas, SMV superior mesenteric vein, ICV ileocecal vein, GCT gastrocolic trunk, ARCV accessory right colic vein, RGEV right gastroepiploic vein, ASPDV anterior superior pancreaticoduodenal vein, ICA ileocecal artery, RCA right colic artery, rt or lt MCA right or left branch of the middle colic artery. The red arrow indicates gastroduodenostomy (Billroth-I method) and the blue arrow indicates ileotransversostomy (triangulating stapling technique). The yellow arrows show the RGEV, which had been cut during the previous gastrectomy

procedures found that PAS did not affect the operative time, blood loss, conversion rate or postoperative complications [10]. Similar results were observed in a series of almost 600 colorectal cancer patients [9], providing further evidence that PAS should not be regarded as a contraindication for laparoscopic colorectal surgery. In contrast, a study involving more than 800 patients found that the rates of conversion (19.6 versus 11.4 %; p 

Laparoscopic right colectomy in patients treated with previous gastrectomy.

Laparoscopic colorectal surgery is increasingly being performed in patients treated with previous abdominal surgery. This is a retrospective study des...
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