ORIGINAL ARTICLE
Minimally Invasive Approach to Chagasic Megacolon: Laparoscopic Rectosigmoidectomy With Posterior End-to-Side Low Colorectal Anastomosis Sergio E. A. Araujo, MD, PhD,*w Alexandre B. Bertoncini, MD,w Sergio C. Nahas, MD, PhD,*w and Ivan Cecconello, MD, PhD*z
Abstract: The effectiveness of anterior resection for the surgical treatment of Chagasic megacolon and the advantages of laparoscopy for performing colorectal surgery are well known. However, current experience with laparoscopic surgery for Chagasic megacolon is restricted. Moreover, associated long-term results remain poorly analyzed. The aims of the present study were to ascertain the immediate results of laparoscopic anterior resection for the surgical treatment of Chagasic megacolon, to identify risk factors associated with adverse outcomes, and to settle late results. A retrospective review of a prospective database was conducted. Between November 2000 and September 2012, 44 patients with Chagasic megacolon underwent laparoscopic anterior resection with posterior end-to-side low colorectal anastomosis. Fifteen (34.1%) patients were male. Mean age was 51.6 years (31 to 77 y). The mean body mass index (BMI) was 22.9 kg/m2 (16.9 to 36.7 kg/m2). Thirty-four previous abdominal operations had been performed. Mean operative time was 265 minutes (105 to 500 min). Four surgeons operated on all cases. Surgeon’s experience with the operation was not associated with surgical time (P = 0.36: linear regression). Mean operative time between patients with and without previous abdominal surgery was similar (237.7 vs. 247.5 min: P = 0.78). There was no association between BMI and the duration of the operation (P = 0.22). Intraoperative complications occurred in 2 (4.5%) cases. Conversion was necessary in 3 (6.8%) cases. There was no association between conversion and previous abdominal surgery (P = 0.56) or between conversion and surgeon’s experience (P = 0.43). However, a significant association (P = 0.01) between BMI and conversion was observed. Postoperative complications occurred in 10 (22.7%) cases. Anastomotic-related complications occurred in 4 cases. Two of them required diversion ileostomy. Restoration of transanal evacuation was achieved in all cases. Mean duration of postoperative hospital stay was 9.8 days (4 to 45 d). Of 19 patients with known clinical late follow-up, only 1 (5.3%) reported use of enemas and 5 (26.3%) reported use of laxatives. Thirteen (68.4%) patients reported daily bowel movements. There was no association between postoperative complications and use of laxatives (P = 0.57). It was concluded that laparoscopic anterior resection for Chagasic megacolon is safe. Obesity was a risk factor for conversion. Restoration of transanal evacuation after surgical treatment of infectious complications was achieved. Minimally invasive surgery for Chagasic megacolon is associated with satisfactory late intestinal function with no significant constipation relapse.
Received for publication March 11, 2013; accepted August 27, 2013. From the *Department of Gastroenterology, University of Sao Paulo Medical School; Divisions of wColorectal Surgery; and zDigestive and Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil. The authors declare no conflicts of interest. Reprints: Sergio E. A. Araujo, MD, PhD, Division of Colorectal Surgery, University of Sao Paulo Medical Center, Av. Dr. Eneas de Carvalho Aguiar, 255, 05403-000 Sao Paulo (SP), Brazil (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Key Words: megacolon, laparoscopy, rectum, constipation, intestinal volvulus, surgical staplers, intraoperative complications, postoperative complications, intestinal fistula, surgical stomas
(Surg Laparosc Endosc Percutan Tech 2014;24:207–212)
A
merican trypanosomiasis (Chagas disease) is a zoonotic disease caused by the autochthonous flagellate protozoan Trypanosoma cruzi.1,2 The transmission vector can be found from the Southern United States to Argentina.3 In 1991, estimated 16 to 18 million were infected in Latin America. Megacolon affects 3% to 7% of chronic Chagas patients, most often after age 30.4 Surgical treatment of Chagasic megacolon has faced several modifications.5 However, pull-through procedures remain the surgical treatment of choice. The development of mechanical sutures6 lead to an abridgement of the surgical treatment of megacolon.7–9 Pull-through operations virtually solved the problem of constipation recurrence after surgery of Chagasic megacolon. After a follow-up period of 3 to 6 years, recurrence became rare, difficult to define, or simply absent.7,10–12 However, morbidity could not be lessened, ranging from 1.6%9 to 58.5%.13 Moreover, pull-through procedures are technically demanding. Mortality occurs in 2.4%11 to 6.4%.10 Aiming at simplifying megacolon surgery, in 1994, the initial results on a completely abdominal rectosigmoidectomy with mechanical end-to-side colorectal anastomosis on the posterior extraperitoneal rectal wall have been published.14,15 Morbidity was 6.9% and there was no mortality. The early good results were confirmed by new publications of our group16 including one focusing on fine late functional results.17 Meanwhile, superior early results associated to the laparoscopic approach in colorectal surgery were demonstrated.18 Superior immediate outcomes can be observed in randomized trials19–21 and in US hospital registries.22,23 The challenges presenting during a laparoscopic approach to megacolon are: to handle a heavily dilated colon segment, the need to thoroughly mobilize the splenic flexure, and to frame a well-irrigated low colorectal anastomosis. Notwithstanding, the experience with laparoscopic surgery in the Pubmedindexed literature is restricted to 1 Brazilian study.24 A laparoscopic approach to megacolon was observed in only 6.8% of all cases in the last Brazilian national registry of laparoscopic colorectal surgery. Yet, after 15 years of the national registry, the most experienced laparoscopic surgeons in the country reported only 325 operated on megacolon patients (nearly 21 cases per year).25 In the present paper, we aimed at evaluating early results of laparoscopic surgical treatment of Chagasic
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megacolon through a rectosigmoidectomy with posterior mechanical end-to-side posterior low colorectal colorectal anastomosis, analyze risk factors related with adverse outcomes, and to assess late clinical intestinal function.
METHODS Patients This study is a retrospective assessment of Chagasic megacolon cases as part of a prospectively collected database on laparoscopic colorectal surgery in 1 universityaffiliated hospital. Between November 2000 and September 2011, 44 patients with Chagasic megacolon were consecutively operated on. Fifteen (34.1%) were male. Mean age was 51.6 years (31 to 77 y). Inclusion criteria were: preoperative diagnosis of Chagasic megacolon by clinical, radiologic, and manometric evaluation with confirmation by pathologic examination, and laparoscopic surgical treatment through rectosigmoidectomy with posterior end-to-side low colorectal colorectal anastomosis with the technique described in the section Surgical technique. Patients with Chagasic megacolon operated on with the same technique through a laparotomy, or operated on using a different laparoscopic technique were excluded. Indications for laparoscopic surgical treatment were: past of megacolon complications (volvulus or fecal impaction) and constipation refractory to medical treatment. After discharge, all patients had scheduled regular follow-up visits at the clinic. Four surgeons operated on all patients. Each surgeon had a personal experience over 300 laparoscopic colectomy cases.
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Five trocars were used. One 11-mm trocar was placed at the umbilicus, one 12-mm trocar at the right inferior quadrant, and one 5-mm trocar on each of the other 3 quadrants. The entire operation was preferably carried out with the use of harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). In all patients, the inferior mesenteric vein was ligated at the very bottom edge of the pancreas and a complete splenic flexure mobilization was conducted. In all cases, the inferior mesenteric artery was ligated with preservation of the superior hypogastric plexus. The pelvic phase of the operation began with sharp dissection of the avascular plane between pelvic and mesorectal fascia from the aortic bifurcation to the level of the levator muscles. The rectal dissection was conducted exclusively on its posterior aspect. At the end of the posterior rectal dissection, the rectum was divided by stapling at the peritoneal reflection level. Rectal transection is accomplished by firing one or more thick tissue-designed charges of an endoscopic stapler (2 mm-height sized staples when closed). The specimen is then extracted through a transverse suprapubic incision after proximal transection of the colon at the level of the inferior mesenteric vein sealed stump.
Studied Variables Study variables were collected in the preoperative, intraoperative, and postoperative periods. Preoperative variables were: body mass index (BMI) (kg/m2) and previous abdominal surgery records. Cesarean deliveries, even having occurred more than once, were recorded as 1 operation, unless if by different incisions. Surgeon’s experience with laparoscopic megacolon surgery was defined as the number of megacolon laparoscopic cases performed by each participating surgeon in the present study. Intraoperative variables were: duration of the operation (min), intraoperative complications, and conversion to laparotomy. Conversion was defined when performing an abdominal incision (1) ahead of schedule; or (2) to accomplish an operative time routinely performed by laparoscopy. Postoperative data were: postoperative complications, need for reoperation, and length of stay. Daily frequency of bowel movements and the use of laxatives or enemas were assessed through records of postoperative visits at the clinic. Regarding immediate surgical results, the influence of clinical variables on the duration of the operation and conversion were evaluated. With respect to long-term results, it was studied the impact of postoperative complications on defecation frequency.
Surgical Technique All patients underwent full mechanical bowel preparation. Antibiotic prophylaxis was administered before anesthesia induction. The patient was placed in semilithotmy position with legs supported on stirrups. Gastric and bladder drainage were routinely used.
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FIGURE 1. Diagrammatic view of posterior end-to-side mechanical low colorectal anastomosis (courtesy of S.C. Nahas, MD). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. r
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After closure of the auxiliary incision, the remaining step of the operation was the construction of the posterior end-to-side colorectal anastomosis using a 33-mm circular stapler (Ethicon Endo-Surgery) just above the anorectal ring (Fig. 1).
Early Results Mean BMI was 22.9kg/m2 (16.9 to 36.7 kg/m2). Thirty-four previous abdominal operations were performed in the 44 patients. One or more previous abdominal operations were noted in 26 (59%) patients. Two or more operations were observed in 8 (18.2%) cases (Table 1). Mean operative time was 265 minutes (105 to 500 min). There were no clinical variables associated to operative time. Patients were operated on by 4 surgeons. Two surgeons operated on 3 cases each. Each of the other 2 operated on 19 cases. A reduction in operative time according to the surgeon’s experience with the operation was not observed (P = 0.36: linear regression). Moreover, no association was found between operative time and presence of previous abdominal surgery (P = 0.78). The mean operative time in patients with previous abdominal operation was 237.7 minutes; and 247.5 minutes for patients without previous operation (P = 0.78). Ultimately, a linear regression analysis revealed no significant association between BMI and operative time (P = 0.22). Intraoperative complications occurred in 2 (4.5%) cases. One patient had a presacral bleeding. In other case, an inadvertent transection of the left ureter was diagnosed. Both complications occurred early in the experience and required conversion to laparotomy. Conversion was necessary in 3 (6.8%) cases. Besides the 2 above-mentioned conversions, the third conversion was due to progression failure, occurring after 350 minutes. Regarding the impact of previous surgery on conversion, it was required in 2 (11.1%) of 18 patients not previously operated on; and in 1 (3.8%) of 26 patients with a history of previous abdominal surgery. Therefore, no association was observed (P = 0.56: Fisher exact test) between previous abdominal surgery and conversion. Likewise, logistic regression analysis found no difference between surgeon’s experience with the operation and conversion (P = 0.43). However, logistic regression analysis did revealed significant correlation [odds ratio (OR) = 1.44, P = 0.01] between BMI and conversion (Fig. 2). Regression analysis estimated that for a unitary increase in BMI, there is 1.44 times increase in conversion risk. Postoperative complications occurred in 10 (22.7%) cases (Table 2). There were 4 (9.2%) anastomotic fistulas. TABLE 1. Previous Abdominal Operations in 44 Patients Submitted to Surgical Treatment of Chagasic Megacolon
Previous Abdominal Operations Cesarean delivery Appendicectomy Conventional Heller cardiomyotomy Hysterectomy Conventional cholecystectomy Esophagectomy Laparoscopic cholecystectomy Laparoscopic Heller cardiomyotomy Uterine myomectomy Anexectomy Total
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N (%) 14 7 4 2 2 1 1 1 1 1 34
(41.2) (20.6) (11.9) (5.9) (5.9) (2.9) (2.9) (2.9) (2.9) (2.9) (100)
FIGURE 2. Correlation between body mass index and conversion in 44 patients with megacolon undergoing laparoscopic rectosigmoidectomy.
Two (4.6%) patients needed laparotomy and ileostomy. The other 2 (4.6%) were treated conservatively. In 2 (4.5%) cases, wound infection was diagnosed. One (2.3%) patient had a surgically corrected trocar site hernia. The patient (2.3%) with the intraoperative ureter injury developed a urinary fistula conservatively managed. Two (4.6%) patients presented with symptomatic anastomotic strictures and underwent successful endoscopic dilations. The 2 patients who underwent ileostomy during reoperation for the treatment of infectious complication underwent uneventful stoma closure. The mean duration of hospital stay was 8.7 days (4 to 45 d).
Late Results Follow-up information about late stool frequency was available for 19 (43.2%) patients. Mean postoperative follow-up was 86 months (33 to 171 mo). Five (26.3%) patients reported regular use of laxatives. No patients reported use of evacuatory enemas. Regarding stool frequency, 13 (68.4%) reported daily bowel movement. Of 14 patients not using laxatives, 3 (21.4%) had developed a postoperative complication. Among 5 patients on laxatives use, 2 (40%) had developed complication. Despite these numbers, there was no association between postoperative complications and requirement for laxatives (P = 0.57: Fisher exact test).
DISCUSSION Brazil is probably the country with the largest worldwide experience on megacolon surgery. Notwithstanding, between 1997 and 2006, there were only 145 individuals operated with megacolon using a minimally invasive approach were published.9,24,26 Only one of these studies was published on Pubmed-indexed literature.24 We aimed at evaluating safety and long-term efficacy derived from laparoscopic retosigmoidectomy with posterior end-to-side low colorectal anastomosis, described using a conventional access in 199414 and known as Habr-Gama technique.16 It was demonstrated in this study that the operation could be safely performed using a laparoscopic approach. Moreover, even after surgical treatment of infectious complications, it was possible to restore transanal evacuation in all cases. In this series, obesity was associated with an increased risk of conversion. Ultimately, an admissible late defecatory frequency could be verified. www.surgical-laparoscopy.com |
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TABLE 2. Postoperative Complications
Postoperative Complications
N
Anastomotic fistula Wound infection Anastomotic stenosis Trocar site hernia Urinary fistula Total
4 2 2 1 1 10
Admittedly, surgery for Chagasic megacolon is cumbersome. The data in Table 3 demonstrate that pullthrough procedures with delayed anastomosis virtually solved the problem of anastomotic fistulas after surgery for Chagasic megacolon. In 1524 cases of 9 studies (considering that the second publication of Moreira is an update of the first), no anastomotic leakage was reported. However, overall morbidity after pull-through procedures could not be as effectively precluded. Infectious complications have occurred in 16.9% of all cases. Moreover, 72 (4.7%) patients died of a surgical complication of an essentially benign condition. We could not extract information on patients who required a stoma after anastomotic or pelvic complications. Hence, this is another important advantage provided by the present study. Therefore, pull-through procedures represent efficient operations in the surgical treatment of Chagasic megacolon. However, technical complexity is an issue, especially when considered low-volume or low-specialization level institutions. Following a streamline approach to the management of this severely incapacitating disease, in 1994, the results of the conventional rectosigmoidectomy with immediate posterior end-to-side low colorectal anastomosis were published by Habr-Gama et al.14 After 43 cases, morbidity was 6.9% and there was no mortality. After the initial report with the technique introduction, published results after this operation carried out by laparotomy come from 127 patients.14,16,31 Complications have occurred in 17 (13.4%), and there were no deaths. Although scientifically debatable, by directly comparing studies in Table 3, it is likely that both mortality (0% vs. 4.7%) and morbidity (13.4% vs. 16.9%) may be lower after abdominal rectosigmoidectomy with posterior low end-to-side colorectal anastomosis compared with pull-trough operations with delayed anastomosis. However, no prospective comparisons or randomized trials are available. Enthusiasm has derived from these results. Nevertheless, feasibility results of the described operation were seldom reported. Souza et al24 promisingly reported on 20
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cases. In this series, there were 2 intraoperative complications: a case of ureteral injury and 1 case of a sigmoid colon penetrating trocar lesion. Length of stay was 5.1 days. There was no conversion or mortality. The mean postoperative follow-up was 11 months and all operated patients had daily bowel movements without laxative use. The most important limitation in the present study is the lack of a control group. However, when laparoscopy was introduced at our institution, it was reserved for benign cases. Therefore, nearly all patients with megacolon were operated on by laparoscopy. Moreover, the results of conventional surgery for megacolon at our institution had already been analyzed.16,17 In addition, this study was conducted at a referral center and referral bias may circumscribe external validity. Cumulative operative time may inform about the surgical experience of a surgical team.32–34 Simons et al35 believe that, for laparoscopic colectomies, the learning curve is completed when the operating time between surgeries varies no greater than 30 minutes. In the present study operative time was not associated to surgeon’s experience with laparoscopic surgery of megacolon. In this study, 4 surgeons operated on 44 cases after 11 years. Lack of power may be implicated on the failure to verify an association between the number of cases operated on and operative time. Previous abdominal surgery may also impact operative time. Coleman et al36 observed an increase in operative time of 18 minutes for patients with a history of laparotomy who underwent a second operation. In the present study, the frequency of previous surgeries reached 59% of cases. Nevertheless, they did not impact operative time. It is known that the formation of adhesions depends on the location of the surgery, its length, and the planned operation.37 Common operations in this series, such as appendectomies and operations performed using a Pfannenstiel access may be more amenable to laparoscopic adhesiolysis. Regarding obesity and surgical outcomes after laparoscopic colectomy, Mustain et al38 examined 9693 patients in the American College of Surgeons National Surgical Quality Improvement Program. These patients underwent elective laparoscopic colectomy. Patients with a BMI >30 had a higher operative time irrespectively of other variables. In contrast, in the present work, linear regression analysis revealed no significant association between BMI and duration of surgery (P = 0.22). These results confirm other small single-institutional series results39 suggesting that obesity does not influence surgical outcomes are. However, these results may result from low power because of a small number of patients, but also because of a relatively small
TABLE 3. Morbidity and Mortality of Abdominoperineal Pull-Through Procedures for the Treatment of Chagasic Megacolon in Brazil
N (%) References
N
Anastomotic Fistula
Moreira10
45 125 180 624 185 83 196 82 49
0 0 0 0 0 0 0 0 0
Reis Neto11 Habr-Gama et al7 Moreira et al27 Cutait28 Sousa and E´sper29 Gama et al30 Fatureto et al13 Pinheiro12
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Septic Complications 24 2 45 105 10 10 37 48 1
r
(53.3) (1.6) (25) (16.8) (5.4) (12) (18.9) (58.5) (2)
Mortality 4 3 6 40 8 3 8 2 2
(5.4) (2.4) (3.3) (6.4) (4.2) (3.6) (3.9) (2.4) (4)
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variation of BMI values (16.9 to 36.7). In other studies where BMI impacted surgical outcomes, the cut off value was around 30,40,41 different to what was observed in this paper where average BMI was 22.90. Intraoperative complications more often result from technical difficulty.42 Recently, Sammour et al41 brought new light to the issue. They analyzed 10 randomized trials with 2159 patients who underwent laparoscopic colectomies. These cases were compared with 1896 patients operated on by laparotomy. The authors observed a higher frequency of intraoperative complications after laparoscopic colectomy (OR = 1.37, P = 0.01). This finding leads to the concept that even among experienced surgeons recruiting patients for randomized trials, laparoscopic colectomy remains a challenging operation. In the case of megacolon, operative times include the proper handling of a sometimes heavily dilated colon, a complete mobilization of the splenic angle, need for posterior low rectal dissection, and construction of a low colorectal anastomosis. In the present study, there were only 2 intraoperative complications associated with completion of the laparoscopic procedure. They occurred in the early experience and in accordance to the rate of intraoperative complications (4.5%) observed in the preliminary institutional experience reported by Souza et al.24 Conversion to open surgery results from failure to progress due to intraoperative technical difficulty. It occurs more frequently during laparoscopic colectomy when compared with other minimally invasive procedures.43 However, in early experience, it is a way of managing an intraoperative complication.44 There is solid evidence regarding association between conversion and previous abdominal surgery.45,46 However, in this study, this relationship could not be demonstrated. The paucity of conversion (6.8%) may have contributed to the finding. Moreover, appendectomy and cesarean section were the most frequently operations. Although speculative, laparoscopic adhesiolysis success after these operations may be more frequently successful, resulting in low risk to conversion. Although laparoscopic colectomy can be safely performed in obese patients, obesity is associated with a high conversion rate.32,40,47–55 In this study, conversion was required in only 3 of the 44 cases. Two of the conversions were necessary in patients with a BMI >30. Although a low mean BMI was measured for the sample, an association between higher BMI and increased risk of conversion (P = 0.01, OR = 1.44) was confirmed. Complications of intestinal anastomoses derive from their location. In a multicenter laparoscopic colectomy prospective trial, Rose et al56 analyzed 4834 consecutive patients in Germany, Austria, and Switzerland. Postoperative complications occurred in 14.0%, and the overall anastomotic leak rate was 3.1% (colon 2.6%, rectum 11.9%). Our experience with the posterior end-to-side low colorectal anastomosis anastomosis is auspicious. In the initial 43 operated on patients,15 there was only 1 (2.3%) case of infectious complication because of a dehiscence at the rectal stump closure. In the updated case series published in 2006 by Nahas et al,16 anastomotic complications have occurred in 2 (4.1%) cases. In the present laparoscopic series, complications of the colorectal anastomosis occurred in 4 (9.1%) cases. Moreover, the fate of the 4 patients with anastomotic complications in the present study should be carefully evaluated. Two of them could be treated with no intervention. And the other 2 patients who underwent r
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ileostomy have undergone successful stoma closure leading to complete restoration of transanal evacuation. This represents a central importance clinical result of our study because of the fact that the follow-up of patients undergoing infectious complications after abdominoperineal operations remains uncertain (Table 3). A major objective of surgical management of megacolon is the settling of constipation. However, published evidence on the issue is restricted. In the present paper, 68.4% of patients with late follow-up reported daily bowel movements at the time of evaluation. Five (26.3%) reported laxative use. Nahas et al17 recently reported similar late results after the same operation performed by laparotomy. Moreover, radiologic evaluation revealed resolution of colonic and rectal dilation after surgery in 19 of 21 evaluated patients. In the present study, the hypothesis of bowel function impairment due to the occurrence of postoperative complications could not be confirmed. In conclusion, the laparoscopic rectosigmoidectomy with posterior end-to-side low colorectal anastomosis can be safely used for the treatment of patients with Chagasic megacolon with an increased risk of conversion for patients with BMI >30. The management of anastomotic complications after surgery led to preservation of transanal evacuation in all cases. The proposition of a minimally invasive abdominal operation associated with low morbidity and good late functional results possibly contributes to the management of patients with Chagasic megacolon using a minimally invasive approach without the need for referral to more specialized centers.
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13. Fatureto MC, Maluf W, Angotti F, et al. Duhame-Haddad operation. Five-year experience. Rev Bras Colo-Pr. 1989;9: 16–18. [Article in Portuguese]. 14. Habr-Gama A, Kiss DR, Bocchini SF, et al. Chagasic megacolon. Treatment by abdominal recto-sigmoidectomy with mechanical colo-rectal termino-lateral anastomosis. Preliminary results. Rev Hosp Clin Fac Med Sao Paulo. 1994; 49:199–203. 15. Habr-Gama A, Kiss DR, Bocchini SF, et al. Chagasic megacolon—surgical treatment by abdominal rectosigmoidctomy with end-to-side colorectal anastomosis. Rev Bras ColoPr. 1994;49:199–203. [Article in Portuguese]. 16. Nahas SC, Habr-Gama A, Nahas CS, et al. Surgical treatment of Chagasic megacolon by abdominal rectosigmoidectomy with immediate posterior end-to-side stapling (Habr-Gama technique). Dis Colon Rectum. 2006;49:1371–1378. 17. Nahas SC, Pinto RA, Dias AR, et al. Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon. Colorectal Dis. 2011;13:317–322. 18. Noel JK, Fahrbach K, Estok R, et al. Minimally invasive colorectal resection outcomes: short-term comparison with open procedures. J Am Coll Surg. 2007;204:291–307. 19. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet. 2002;359:2224–2229. 20. Trial C. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050–2059. 21. Leung KL, Kwok SP, Lam SC, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. Lancet. 2004;363:1187–1192. 22. Delaney CP, Chang E, Senagore AJ, et al. Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg. 2008; 247:819–824. 23. Kennedy GD, Heise C, Rajamanickam V, et al. Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program. Ann Surg. 2009;249:596–601. 24. Souza JV, Carmel AP, Martins FA, et al. Surgical treatment for chagasic megacolon: video endoscopy approach. Surg Laparosc Endosc. 1997;7:166–170. 25. Valarini R, Campos FGCM. Results of the Brazilian National Laparoscopic Surgery Registry. Rev Bras Colo-Pr. 2008;28: 145–155. [Article in Portuguese]. 26. Nahas SC, Dias AR, Dainezi MA, et al. Laparoscopic surgery for the treatment of Chagasic megacolon. Rev Bras Colo-Pr. 2006;26:470–474. [Article in Portuguese]. 27. Moreira H, Rezende JM, Sebba F, et al. Chagasic megacolon. Rev bras Colo-Pr. 1983;3:152–162. [Article in Portuguese]. 28. Cutait DE. Current status of pull-through operations. Rev Bras Colo-Pr. 1984;4:73–79. [Article in Portuguese]. 29. Sousa AG, E´sper FE. Surgical treatment of acquired megacolon. Rev Col Bras Cir. 1985;12:13–17. [Article in Portuguese]. 30. Gama RC, Costa JH, Azevedo IF. Surgical treatment of Chagasic megacolon by Duhamel-Haddad technique. Experience of the Goiania General Hospital. Analysis of 204 cases. Rev Bras Colo-Pr. 1986;6:84–88. [Article in Portuguese]. 31. Silva JH, Sodre´ LA, Matheus CO, et al. Surgical treatment of Chagasic megacolon using abdominal proctocolectomy with mechanical end-to-side colorectal anastomosis. Rev Col Bras Cir. 1999;26:285–289. [Article in Portuguese]. 32. Schlachta CM, Mamazza J, Seshadri PA, et al. Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum. 2001;44:217–222. 33. Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg. 2005;242: 83–91.
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34. Li JC, Hon SS, Ng SS, et al. The learning curve for laparoscopic colectomy: experience of a surgical fellow in an university colorectal unit. Surg Endosc. 2009;23:1603–1608. 35. Simons AJ, Anthone GJ, Ortega AE, et al. Laparoscopicassisted colectomy learning curve. Dis Colon Rectum. 1995; 38:600–603. 36. Coleman MG, McLain AD, Moran BJ. Impact of previous surgery on time taken for incision and division of adhesions during laparotomy. Dis Colon Rectum. 2000;43:1297–1299. 37. Curet MJ. Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy. Surg Clin North Am. 2000;80:1093–1110. 38. Mustain WC, Davenport DL, Hourigan JS, et al. Obesity and laparoscopic colectomy: outcomes from the ACS-NSQIP database. Dis Colon Rectum. 2012;55:429–435. 39. Leroy J, Ananian P, Rubino F, et al. The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy. Ann Surg. 2005;241:69–76. 40. Delaney CP, Pokala N, Senagore AJ, et al. Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy. Dis Colon Rectum. 2005;48:975–981. 41. Sammour T, Kahokehr A, Srinivasa S, et al. Laparoscopic colorectal surgery is associated with a higher intraoperative complication rate than open surgery. Ann Surg. 2011;253:35–43. 42. Agachan F, Joo JS, Weiss EG, et al. Intraoperative laparoscopic complications. Are we getting better? Dis Colon Rectum. 1996;39(10 Suppl):S14–S19. 43. Monson JR, Hill AD, Darzi A. Laparoscopic colonic surgery. Br J Surg. 1995;82:150–157. 44. Scheidbach H, Garlipp B, Oberlander H, et al. Conversion in laparoscopic colorectal cancer surgery: impact on short- and long-term outcome. J Laparoendosc Adv Surg Tech A. 2011;21: 923–927. 45. Arteaga Gonzalez I, Martin Malagon A, Lopez-Tomassetti Fernandez EM, et al. Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study. Surg Laparosc Endosc Percutan Tech. 2006;16:8–11. 46. Barleben A, Gandhi D, Nguyen XM, et al. Is laparoscopic colon surgery appropriate in patients who have had previous abdominal surgery? Am Surg. 2009;75:1015–1019. 47. Smadja C, Sbai Idrissi M, Tahrat M, et al. Elective laparoscopic sigmoid colectomy for diverticulitis. Results of a prospective study. Surg Endosc. 1999;13:645–648. 48. Dean PA, Beart RW Jr, Nelson H, et al. Laparoscopic-assisted segmental colectomy: early Mayo Clinic experience. Mayo Clin Proc. 1994;69:834–840. 49. Gervaz P, Pikarsky A, Utech M, et al. Converted laparoscopic colorectal surgery. Surg Endosc. 2001;15:827–832. 50. Schlachta CM, Mamazza J, Seshadri PA, et al. Predicting conversion to open surgery in laparoscopic colorectal resections. A simple clinical model. Surg Endosc. 2000;14:1114–1117. 51. Marusch F, Gastinger I, Schneider C, et al. Importance of conversion for results obtained with laparoscopic colorectal surgery. Dis Colon Rectum. 2001;44:207–214; discussion 214-6. 52. Senagore AJ, Delaney CP, Madboulay K, et al. Laparoscopic colectomy in obese and nonobese patients. J Gastrointest Surg. 2003;7:558–561. 53. Pikarsky AJ, Saida Y, Yamaguchi T, et al. Is obesity a highrisk factor for laparoscopic colorectal surgery? Surg Endosc. 2002;16:855–858. 54. Kamoun S, Alves A, Bretagnol F, et al. Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a casematched study of 180 patients. Am J Surg. 2009;198:450–455. 55. Zhou Y, Wu L, Li X, et al. Outcome of laparoscopic colorectal surgery in obese and nonobese patients: a meta-analysis. Surg Endosc. 2012;26:783–789. 56. Rose J, Schneider C, Yildirim C, et al. Complications in laparoscopic colorectal surgery: results of a multicentre trial. Tech Coloproctol. 2004;8(suppl 1):s25–s28.
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Minimally Invasive Approach to Chagasic Megacolon: Laparoscopic Rectosigmoidectomy With Posterior End-to-Side Low Colorectal Anastomosis Sergio E. A. Araujo, MD, PhD,*w Alexandre B. Bertoncini, MD,w Sergio C. Nahas, MD, PhD,*w and Ivan Cecconello, MD, PhD*z
Abstract: The effectiveness of anterior resection for the surgical treatment of Chagasic megacolon and the advantages of laparoscopy for performing colorectal surgery are well known. However, current experience with laparoscopic surgery for Chagasic megacolon is restricted. Moreover, associated long-term results remain poorly analyzed. The aims of the present study were to ascertain the immediate results of laparoscopic anterior resection for the surgical treatment of Chagasic megacolon, to identify risk factors associated with adverse outcomes, and to settle late results. A retrospective review of a prospective database was conducted. Between November 2000 and September 2012, 44 patients with Chagasic megacolon underwent laparoscopic anterior resection with posterior end-to-side low colorectal anastomosis. Fifteen (34.1%) patients were male. Mean age was 51.6 years (31 to 77 y). The mean body mass index (BMI) was 22.9 kg/m2 (16.9 to 36.7 kg/m2). Thirty-four previous abdominal operations had been performed. Mean operative time was 265 minutes (105 to 500 min). Four surgeons operated on all cases. Surgeon’s experience with the operation was not associated with surgical time (P = 0.36: linear regression). Mean operative time between patients with and without previous abdominal surgery was similar (237.7 vs. 247.5 min: P = 0.78). There was no association between BMI and the duration of the operation (P = 0.22). Intraoperative complications occurred in 2 (4.5%) cases. Conversion was necessary in 3 (6.8%) cases. There was no association between conversion and previous abdominal surgery (P = 0.56) or between conversion and surgeon’s experience (P = 0.43). However, a significant association (P = 0.01) between BMI and conversion was observed. Postoperative complications occurred in 10 (22.7%) cases. Anastomotic-related complications occurred in 4 cases. Two of them required diversion ileostomy. Restoration of transanal evacuation was achieved in all cases. Mean duration of postoperative hospital stay was 9.8 days (4 to 45 d). Of 19 patients with known clinical late follow-up, only 1 (5.3%) reported use of enemas and 5 (26.3%) reported use of laxatives. Thirteen (68.4%) patients reported daily bowel movements. There was no association between postoperative complications and use of laxatives (P = 0.57). It was concluded that laparoscopic anterior resection for Chagasic megacolon is safe. Obesity was a risk factor for conversion. Restoration of transanal evacuation after surgical treatment of infectious complications was achieved. Minimally invasive surgery for Chagasic megacolon is associated with satisfactory late intestinal function with no significant constipation relapse.
Received for publication March 11, 2013; accepted August 27, 2013. From the *Department of Gastroenterology, University of Sao Paulo Medical School; Divisions of wColorectal Surgery; and zDigestive and Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil. The authors declare no conflicts of interest. Reprints: Sergio E. A. Araujo, MD, PhD, Division of Colorectal Surgery, University of Sao Paulo Medical Center, Av. Dr. Eneas de Carvalho Aguiar, 255, 05403-000 Sao Paulo (SP), Brazil (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Key Words: megacolon, laparoscopy, rectum, constipation, intestinal volvulus, surgical staplers, intraoperative complications, postoperative complications, intestinal fistula, surgical stomas
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A
merican trypanosomiasis (Chagas disease) is a zoonotic disease caused by the autochthonous flagellate protozoan Trypanosoma cruzi.1,2 The transmission vector can be found from the Southern United States to Argentina.3 In 1991, estimated 16 to 18 million were infected in Latin America. Megacolon affects 3% to 7% of chronic Chagas patients, most often after age 30.4 Surgical treatment of Chagasic megacolon has faced several modifications.5 However, pull-through procedures remain the surgical treatment of choice. The development of mechanical sutures6 lead to an abridgement of the surgical treatment of megacolon.7–9 Pull-through operations virtually solved the problem of constipation recurrence after surgery of Chagasic megacolon. After a follow-up period of 3 to 6 years, recurrence became rare, difficult to define, or simply absent.7,10–12 However, morbidity could not be lessened, ranging from 1.6%9 to 58.5%.13 Moreover, pull-through procedures are technically demanding. Mortality occurs in 2.4%11 to 6.4%.10 Aiming at simplifying megacolon surgery, in 1994, the initial results on a completely abdominal rectosigmoidectomy with mechanical end-to-side colorectal anastomosis on the posterior extraperitoneal rectal wall have been published.14,15 Morbidity was 6.9% and there was no mortality. The early good results were confirmed by new publications of our group16 including one focusing on fine late functional results.17 Meanwhile, superior early results associated to the laparoscopic approach in colorectal surgery were demonstrated.18 Superior immediate outcomes can be observed in randomized trials19–21 and in US hospital registries.22,23 The challenges presenting during a laparoscopic approach to megacolon are: to handle a heavily dilated colon segment, the need to thoroughly mobilize the splenic flexure, and to frame a well-irrigated low colorectal anastomosis. Notwithstanding, the experience with laparoscopic surgery in the Pubmedindexed literature is restricted to 1 Brazilian study.24 A laparoscopic approach to megacolon was observed in only 6.8% of all cases in the last Brazilian national registry of laparoscopic colorectal surgery. Yet, after 15 years of the national registry, the most experienced laparoscopic surgeons in the country reported only 325 operated on megacolon patients (nearly 21 cases per year).25 In the present paper, we aimed at evaluating early results of laparoscopic surgical treatment of Chagasic
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megacolon through a rectosigmoidectomy with posterior mechanical end-to-side posterior low colorectal colorectal anastomosis, analyze risk factors related with adverse outcomes, and to assess late clinical intestinal function.
METHODS Patients This study is a retrospective assessment of Chagasic megacolon cases as part of a prospectively collected database on laparoscopic colorectal surgery in 1 universityaffiliated hospital. Between November 2000 and September 2011, 44 patients with Chagasic megacolon were consecutively operated on. Fifteen (34.1%) were male. Mean age was 51.6 years (31 to 77 y). Inclusion criteria were: preoperative diagnosis of Chagasic megacolon by clinical, radiologic, and manometric evaluation with confirmation by pathologic examination, and laparoscopic surgical treatment through rectosigmoidectomy with posterior end-to-side low colorectal colorectal anastomosis with the technique described in the section Surgical technique. Patients with Chagasic megacolon operated on with the same technique through a laparotomy, or operated on using a different laparoscopic technique were excluded. Indications for laparoscopic surgical treatment were: past of megacolon complications (volvulus or fecal impaction) and constipation refractory to medical treatment. After discharge, all patients had scheduled regular follow-up visits at the clinic. Four surgeons operated on all patients. Each surgeon had a personal experience over 300 laparoscopic colectomy cases.
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Five trocars were used. One 11-mm trocar was placed at the umbilicus, one 12-mm trocar at the right inferior quadrant, and one 5-mm trocar on each of the other 3 quadrants. The entire operation was preferably carried out with the use of harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). In all patients, the inferior mesenteric vein was ligated at the very bottom edge of the pancreas and a complete splenic flexure mobilization was conducted. In all cases, the inferior mesenteric artery was ligated with preservation of the superior hypogastric plexus. The pelvic phase of the operation began with sharp dissection of the avascular plane between pelvic and mesorectal fascia from the aortic bifurcation to the level of the levator muscles. The rectal dissection was conducted exclusively on its posterior aspect. At the end of the posterior rectal dissection, the rectum was divided by stapling at the peritoneal reflection level. Rectal transection is accomplished by firing one or more thick tissue-designed charges of an endoscopic stapler (2 mm-height sized staples when closed). The specimen is then extracted through a transverse suprapubic incision after proximal transection of the colon at the level of the inferior mesenteric vein sealed stump.
Studied Variables Study variables were collected in the preoperative, intraoperative, and postoperative periods. Preoperative variables were: body mass index (BMI) (kg/m2) and previous abdominal surgery records. Cesarean deliveries, even having occurred more than once, were recorded as 1 operation, unless if by different incisions. Surgeon’s experience with laparoscopic megacolon surgery was defined as the number of megacolon laparoscopic cases performed by each participating surgeon in the present study. Intraoperative variables were: duration of the operation (min), intraoperative complications, and conversion to laparotomy. Conversion was defined when performing an abdominal incision (1) ahead of schedule; or (2) to accomplish an operative time routinely performed by laparoscopy. Postoperative data were: postoperative complications, need for reoperation, and length of stay. Daily frequency of bowel movements and the use of laxatives or enemas were assessed through records of postoperative visits at the clinic. Regarding immediate surgical results, the influence of clinical variables on the duration of the operation and conversion were evaluated. With respect to long-term results, it was studied the impact of postoperative complications on defecation frequency.
Surgical Technique All patients underwent full mechanical bowel preparation. Antibiotic prophylaxis was administered before anesthesia induction. The patient was placed in semilithotmy position with legs supported on stirrups. Gastric and bladder drainage were routinely used.
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FIGURE 1. Diagrammatic view of posterior end-to-side mechanical low colorectal anastomosis (courtesy of S.C. Nahas, MD). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. r
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After closure of the auxiliary incision, the remaining step of the operation was the construction of the posterior end-to-side colorectal anastomosis using a 33-mm circular stapler (Ethicon Endo-Surgery) just above the anorectal ring (Fig. 1).
Early Results Mean BMI was 22.9kg/m2 (16.9 to 36.7 kg/m2). Thirty-four previous abdominal operations were performed in the 44 patients. One or more previous abdominal operations were noted in 26 (59%) patients. Two or more operations were observed in 8 (18.2%) cases (Table 1). Mean operative time was 265 minutes (105 to 500 min). There were no clinical variables associated to operative time. Patients were operated on by 4 surgeons. Two surgeons operated on 3 cases each. Each of the other 2 operated on 19 cases. A reduction in operative time according to the surgeon’s experience with the operation was not observed (P = 0.36: linear regression). Moreover, no association was found between operative time and presence of previous abdominal surgery (P = 0.78). The mean operative time in patients with previous abdominal operation was 237.7 minutes; and 247.5 minutes for patients without previous operation (P = 0.78). Ultimately, a linear regression analysis revealed no significant association between BMI and operative time (P = 0.22). Intraoperative complications occurred in 2 (4.5%) cases. One patient had a presacral bleeding. In other case, an inadvertent transection of the left ureter was diagnosed. Both complications occurred early in the experience and required conversion to laparotomy. Conversion was necessary in 3 (6.8%) cases. Besides the 2 above-mentioned conversions, the third conversion was due to progression failure, occurring after 350 minutes. Regarding the impact of previous surgery on conversion, it was required in 2 (11.1%) of 18 patients not previously operated on; and in 1 (3.8%) of 26 patients with a history of previous abdominal surgery. Therefore, no association was observed (P = 0.56: Fisher exact test) between previous abdominal surgery and conversion. Likewise, logistic regression analysis found no difference between surgeon’s experience with the operation and conversion (P = 0.43). However, logistic regression analysis did revealed significant correlation [odds ratio (OR) = 1.44, P = 0.01] between BMI and conversion (Fig. 2). Regression analysis estimated that for a unitary increase in BMI, there is 1.44 times increase in conversion risk. Postoperative complications occurred in 10 (22.7%) cases (Table 2). There were 4 (9.2%) anastomotic fistulas. TABLE 1. Previous Abdominal Operations in 44 Patients Submitted to Surgical Treatment of Chagasic Megacolon
Previous Abdominal Operations Cesarean delivery Appendicectomy Conventional Heller cardiomyotomy Hysterectomy Conventional cholecystectomy Esophagectomy Laparoscopic cholecystectomy Laparoscopic Heller cardiomyotomy Uterine myomectomy Anexectomy Total
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N (%) 14 7 4 2 2 1 1 1 1 1 34
(41.2) (20.6) (11.9) (5.9) (5.9) (2.9) (2.9) (2.9) (2.9) (2.9) (100)
FIGURE 2. Correlation between body mass index and conversion in 44 patients with megacolon undergoing laparoscopic rectosigmoidectomy.
Two (4.6%) patients needed laparotomy and ileostomy. The other 2 (4.6%) were treated conservatively. In 2 (4.5%) cases, wound infection was diagnosed. One (2.3%) patient had a surgically corrected trocar site hernia. The patient (2.3%) with the intraoperative ureter injury developed a urinary fistula conservatively managed. Two (4.6%) patients presented with symptomatic anastomotic strictures and underwent successful endoscopic dilations. The 2 patients who underwent ileostomy during reoperation for the treatment of infectious complication underwent uneventful stoma closure. The mean duration of hospital stay was 8.7 days (4 to 45 d).
Late Results Follow-up information about late stool frequency was available for 19 (43.2%) patients. Mean postoperative follow-up was 86 months (33 to 171 mo). Five (26.3%) patients reported regular use of laxatives. No patients reported use of evacuatory enemas. Regarding stool frequency, 13 (68.4%) reported daily bowel movement. Of 14 patients not using laxatives, 3 (21.4%) had developed a postoperative complication. Among 5 patients on laxatives use, 2 (40%) had developed complication. Despite these numbers, there was no association between postoperative complications and requirement for laxatives (P = 0.57: Fisher exact test).
DISCUSSION Brazil is probably the country with the largest worldwide experience on megacolon surgery. Notwithstanding, between 1997 and 2006, there were only 145 individuals operated with megacolon using a minimally invasive approach were published.9,24,26 Only one of these studies was published on Pubmed-indexed literature.24 We aimed at evaluating safety and long-term efficacy derived from laparoscopic retosigmoidectomy with posterior end-to-side low colorectal anastomosis, described using a conventional access in 199414 and known as Habr-Gama technique.16 It was demonstrated in this study that the operation could be safely performed using a laparoscopic approach. Moreover, even after surgical treatment of infectious complications, it was possible to restore transanal evacuation in all cases. In this series, obesity was associated with an increased risk of conversion. Ultimately, an admissible late defecatory frequency could be verified. www.surgical-laparoscopy.com |
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TABLE 2. Postoperative Complications
Postoperative Complications
N
Anastomotic fistula Wound infection Anastomotic stenosis Trocar site hernia Urinary fistula Total
4 2 2 1 1 10
Admittedly, surgery for Chagasic megacolon is cumbersome. The data in Table 3 demonstrate that pullthrough procedures with delayed anastomosis virtually solved the problem of anastomotic fistulas after surgery for Chagasic megacolon. In 1524 cases of 9 studies (considering that the second publication of Moreira is an update of the first), no anastomotic leakage was reported. However, overall morbidity after pull-through procedures could not be as effectively precluded. Infectious complications have occurred in 16.9% of all cases. Moreover, 72 (4.7%) patients died of a surgical complication of an essentially benign condition. We could not extract information on patients who required a stoma after anastomotic or pelvic complications. Hence, this is another important advantage provided by the present study. Therefore, pull-through procedures represent efficient operations in the surgical treatment of Chagasic megacolon. However, technical complexity is an issue, especially when considered low-volume or low-specialization level institutions. Following a streamline approach to the management of this severely incapacitating disease, in 1994, the results of the conventional rectosigmoidectomy with immediate posterior end-to-side low colorectal anastomosis were published by Habr-Gama et al.14 After 43 cases, morbidity was 6.9% and there was no mortality. After the initial report with the technique introduction, published results after this operation carried out by laparotomy come from 127 patients.14,16,31 Complications have occurred in 17 (13.4%), and there were no deaths. Although scientifically debatable, by directly comparing studies in Table 3, it is likely that both mortality (0% vs. 4.7%) and morbidity (13.4% vs. 16.9%) may be lower after abdominal rectosigmoidectomy with posterior low end-to-side colorectal anastomosis compared with pull-trough operations with delayed anastomosis. However, no prospective comparisons or randomized trials are available. Enthusiasm has derived from these results. Nevertheless, feasibility results of the described operation were seldom reported. Souza et al24 promisingly reported on 20
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cases. In this series, there were 2 intraoperative complications: a case of ureteral injury and 1 case of a sigmoid colon penetrating trocar lesion. Length of stay was 5.1 days. There was no conversion or mortality. The mean postoperative follow-up was 11 months and all operated patients had daily bowel movements without laxative use. The most important limitation in the present study is the lack of a control group. However, when laparoscopy was introduced at our institution, it was reserved for benign cases. Therefore, nearly all patients with megacolon were operated on by laparoscopy. Moreover, the results of conventional surgery for megacolon at our institution had already been analyzed.16,17 In addition, this study was conducted at a referral center and referral bias may circumscribe external validity. Cumulative operative time may inform about the surgical experience of a surgical team.32–34 Simons et al35 believe that, for laparoscopic colectomies, the learning curve is completed when the operating time between surgeries varies no greater than 30 minutes. In the present study operative time was not associated to surgeon’s experience with laparoscopic surgery of megacolon. In this study, 4 surgeons operated on 44 cases after 11 years. Lack of power may be implicated on the failure to verify an association between the number of cases operated on and operative time. Previous abdominal surgery may also impact operative time. Coleman et al36 observed an increase in operative time of 18 minutes for patients with a history of laparotomy who underwent a second operation. In the present study, the frequency of previous surgeries reached 59% of cases. Nevertheless, they did not impact operative time. It is known that the formation of adhesions depends on the location of the surgery, its length, and the planned operation.37 Common operations in this series, such as appendectomies and operations performed using a Pfannenstiel access may be more amenable to laparoscopic adhesiolysis. Regarding obesity and surgical outcomes after laparoscopic colectomy, Mustain et al38 examined 9693 patients in the American College of Surgeons National Surgical Quality Improvement Program. These patients underwent elective laparoscopic colectomy. Patients with a BMI >30 had a higher operative time irrespectively of other variables. In contrast, in the present work, linear regression analysis revealed no significant association between BMI and duration of surgery (P = 0.22). These results confirm other small single-institutional series results39 suggesting that obesity does not influence surgical outcomes are. However, these results may result from low power because of a small number of patients, but also because of a relatively small
TABLE 3. Morbidity and Mortality of Abdominoperineal Pull-Through Procedures for the Treatment of Chagasic Megacolon in Brazil
N (%) References
N
Anastomotic Fistula
Moreira10
45 125 180 624 185 83 196 82 49
0 0 0 0 0 0 0 0 0
Reis Neto11 Habr-Gama et al7 Moreira et al27 Cutait28 Sousa and E´sper29 Gama et al30 Fatureto et al13 Pinheiro12
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Septic Complications 24 2 45 105 10 10 37 48 1
r
(53.3) (1.6) (25) (16.8) (5.4) (12) (18.9) (58.5) (2)
Mortality 4 3 6 40 8 3 8 2 2
(5.4) (2.4) (3.3) (6.4) (4.2) (3.6) (3.9) (2.4) (4)
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variation of BMI values (16.9 to 36.7). In other studies where BMI impacted surgical outcomes, the cut off value was around 30,40,41 different to what was observed in this paper where average BMI was 22.90. Intraoperative complications more often result from technical difficulty.42 Recently, Sammour et al41 brought new light to the issue. They analyzed 10 randomized trials with 2159 patients who underwent laparoscopic colectomies. These cases were compared with 1896 patients operated on by laparotomy. The authors observed a higher frequency of intraoperative complications after laparoscopic colectomy (OR = 1.37, P = 0.01). This finding leads to the concept that even among experienced surgeons recruiting patients for randomized trials, laparoscopic colectomy remains a challenging operation. In the case of megacolon, operative times include the proper handling of a sometimes heavily dilated colon, a complete mobilization of the splenic angle, need for posterior low rectal dissection, and construction of a low colorectal anastomosis. In the present study, there were only 2 intraoperative complications associated with completion of the laparoscopic procedure. They occurred in the early experience and in accordance to the rate of intraoperative complications (4.5%) observed in the preliminary institutional experience reported by Souza et al.24 Conversion to open surgery results from failure to progress due to intraoperative technical difficulty. It occurs more frequently during laparoscopic colectomy when compared with other minimally invasive procedures.43 However, in early experience, it is a way of managing an intraoperative complication.44 There is solid evidence regarding association between conversion and previous abdominal surgery.45,46 However, in this study, this relationship could not be demonstrated. The paucity of conversion (6.8%) may have contributed to the finding. Moreover, appendectomy and cesarean section were the most frequently operations. Although speculative, laparoscopic adhesiolysis success after these operations may be more frequently successful, resulting in low risk to conversion. Although laparoscopic colectomy can be safely performed in obese patients, obesity is associated with a high conversion rate.32,40,47–55 In this study, conversion was required in only 3 of the 44 cases. Two of the conversions were necessary in patients with a BMI >30. Although a low mean BMI was measured for the sample, an association between higher BMI and increased risk of conversion (P = 0.01, OR = 1.44) was confirmed. Complications of intestinal anastomoses derive from their location. In a multicenter laparoscopic colectomy prospective trial, Rose et al56 analyzed 4834 consecutive patients in Germany, Austria, and Switzerland. Postoperative complications occurred in 14.0%, and the overall anastomotic leak rate was 3.1% (colon 2.6%, rectum 11.9%). Our experience with the posterior end-to-side low colorectal anastomosis anastomosis is auspicious. In the initial 43 operated on patients,15 there was only 1 (2.3%) case of infectious complication because of a dehiscence at the rectal stump closure. In the updated case series published in 2006 by Nahas et al,16 anastomotic complications have occurred in 2 (4.1%) cases. In the present laparoscopic series, complications of the colorectal anastomosis occurred in 4 (9.1%) cases. Moreover, the fate of the 4 patients with anastomotic complications in the present study should be carefully evaluated. Two of them could be treated with no intervention. And the other 2 patients who underwent r
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ileostomy have undergone successful stoma closure leading to complete restoration of transanal evacuation. This represents a central importance clinical result of our study because of the fact that the follow-up of patients undergoing infectious complications after abdominoperineal operations remains uncertain (Table 3). A major objective of surgical management of megacolon is the settling of constipation. However, published evidence on the issue is restricted. In the present paper, 68.4% of patients with late follow-up reported daily bowel movements at the time of evaluation. Five (26.3%) reported laxative use. Nahas et al17 recently reported similar late results after the same operation performed by laparotomy. Moreover, radiologic evaluation revealed resolution of colonic and rectal dilation after surgery in 19 of 21 evaluated patients. In the present study, the hypothesis of bowel function impairment due to the occurrence of postoperative complications could not be confirmed. In conclusion, the laparoscopic rectosigmoidectomy with posterior end-to-side low colorectal anastomosis can be safely used for the treatment of patients with Chagasic megacolon with an increased risk of conversion for patients with BMI >30. The management of anastomotic complications after surgery led to preservation of transanal evacuation in all cases. The proposition of a minimally invasive abdominal operation associated with low morbidity and good late functional results possibly contributes to the management of patients with Chagasic megacolon using a minimally invasive approach without the need for referral to more specialized centers.
REFERENCES 1. Chagas C. New species of man morbid, produced by Trypanosoma (Trypanosoma cruzi). Foreword. Brasil Med. 1909;23:159. [Article in Portuguese]. 2. Chagas C. New human trypanosomiasis. Mem Inst Osw Cruz. 1909;1:159. [Article in Portuguese]. 3. Vinhaes MC, Dias JC. Chagas disease in Brazil. Cad Saude Publica. 2000;16(suppl 2):7–12. 4. Dias JCP, Coura JR. Epidemiologia. In: Dias JCP, Coura JR, eds. Clı´nica e terapeˆutica da doenc¸a de Chagas: uma abordagem pra´tica para o clı´nico geral. Rio de Janeiro: Fiocruz; 1997:33–65. 5. Netinho JG, Cunrath GS, Ronchi LS. Rectosigmoidectomy with ileal loop interposition: a new surgical method for the treatment of chagasic megacolon. Dis Colon Rectum. 2002;45:1387–1392. 6. Steichen FM, Talbert JL, Ravitch M. Primary side-to-side colorectal anastomosis in the Duhamel operation for Hirschsprung’s disease. Surgery. 1968;64:475–483. 7. Habr-Gama A, Goffi FS, Raia A, et al. Surgical treatment of megacolon—Duhamel-Haddad operation. Rev Col Bras Cir. 1982;9:25–31. [Article in Portuguese]. 8. Lins Neto MAF. Operac¸a˜o de Duhamel modificada com anastomose colorretal imediata para o tratamento do megaco´lon chaga´sico: te´cnica e resultados. Tese (Mestrado). Universidade de Sa˜o Paulo: Faculdade de Medicina; 1997. 9. Reis Neto JA, Pedroso MA, Lupinacci RA, et al. Acquired megacolon: physiopatologic perspectives to laparoscopic treatment. Rev Bras Colo-Proct. 2004;24:49–62. [Article in Portuguese]. 10. Moreira H. Surgical treatment of Chagasic megacolon by Duhamel-Haddad technique: personal experience. Arq Gastroenterol. 1971;8:185–190. [Article in Portuguese]. 11. Reis Neto JA. Late results of Duhamel operation for the surgical treatment of acquired megacolon. AMB Rev Assoc Med Bras. 1972;18:57. [Article in Portuguese]. 12. Pinheiro HB. Surgical approach to Chagasic megacolon. Rev Bras Colo-Pr. 1990;10:139–142. [Article in Portuguese].
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