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Objective To compare long-term oncologic outcomes between laparoscopic and open surgery for rectal cancer and to identify independent predictors of survival. Background Few randomized trials comparing laparoscopic and open surgery for rectal cancer have reported long-term survival data. Methods Data from the 3 randomized controlled trials comparing curative laparoscopic (n=136) and open surgery (n=142) for upper, mid, and low rectal cancer conducted at the Prince of Wales Hospital, Hong Kong, between September 1993 and August 2007 were pooled together for this analysis. Survival and disease status were updated to February 2012. Survival was calculated using the Kaplan-Meier method, and independent predictors of survival were determined using the Cox regression analysis. Results The demographic data of the 2 groups were comparable. The median follow-up time of living patients was 124.5 months in the laparoscopic group and 136.6 months in the open group. At 10 years, there were no significant differences in locoregional recurrence (5.5% vs. 9.3%; P=0.296), cancer-specific survival (82.5% vs. 77.6%; P=0.443), and overall survival (63.0% vs. 61.1%; P=0.505) between the laparoscopic and open groups. There was a trend toward lower recurrence rate at 10 years in the laparoscopic group than in the open group among patients with stage III cancer (P=0.078). The Cox regression analysis showed that stage III cancer, lymphovascular permeation, and blood transfusion, but not the operative approach, were independent predictors of poorer cancer-specific survival. Conclusions This pooled analysis with a follow-up of more than 10 years confirms the long-term oncologic safety of laparoscopic surgery for rectal cancer.

This study aimed to evaluate the learning curve for laparoscopic colectomy of a surgical fellow in an university colorectal unit using a structured training protocol.This study analyzed the data from 100 consecutive patients who had laparoscopic colectomy performed by a surgical fellow between 11/2004 and 12/2007. The structured training protocol required the fellow to assist more than 40 laparoscopic colectomies before embarking on his first case. Rectosigmoidectomy was prioritized during the initial experience. Operative times were analyzed to represent the learning curve. Other outcome data including conversion and operative outcome were also evaluated.The following procedures were performed: 49 rectosigmoidectomies, 38 right colon resections, and 13 other resections. Median operative time was 150 min, and conversion rate was 1%. Overall postoperative morbidity rate was 28% (major morbidity 3%). Three patients required early reoperation. There was no operative death. Median hospital stay was 8 days. Operative times reached their lowest point at period of cases 45-50, and remained relatively stable afterwards. Comparing the first 50 and second 50 cases, the only difference observed was more frequent presence of a supervisor in the theater in the first 50 cases (74% versus 52%, p = 0.02), while the other parameters including types of procedures, postoperative recovery, hospital stay, and morbidity rate were not different.Our results indicated that laparoscopic colectomy training can be safely performed under a structured protocol. The surgeon can perform laparoscopic colectomies more independently after 50 cases, without jeopardizing the clinical outcome.

Laparoscopic resection of colonic cancer has been shown to improve postoperative recovery without jeopardizing tumor clearance and survival, but information on low rectal cancer is scarce. The aim of this randomized trial was to compare postoperative recovery between laparoscopic-assisted versus open abdominoperineal resection (APR) in patients with low rectal cancer. Recurrence and survival data were also recorded and compared between the two groups. Between September 1994 and February 2005, 99 patients with low rectal cancer were randomized to receive either laparoscopic-assisted (51 patients) or conventional open (48 patients) APR. The median follow-up time of living patients was about 90 months for both groups. The primary and secondary endpoints of the study were postoperative recovery and survival, respectively. Data were analyzed by intention-to-treat principle. The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with earlier return of bowel function (P

Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchronous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms is technically feasible and safe.

Emergency colectomy is well accepted for treating complicated right-sided colonic diverticulitis. However, the role of colectomy for uncomplicated diverticulitis is not well defined. The aim of this study was to evaluate the short-term and long-term surgical outcome of uncomplicated right-sided diverticulitis in our locality. Retrospective chart review of patients operated for right-sided diverticulitis over a 20-year period was conducted. Recurrent attacks of right-sided diverticulitis, re-operation rate and re-hospitalisation rate were the long-term parameters of interest. An updated telephone interview was carried out for all surviving patients. Seventy-four patients (35 males and 39 females), median age 35.5 (range 16–70) years, were operated for uncomplicated diverticulitis. Thirty patients underwent colectomy, whereas the others underwent appendectomy with diverticulectomy (n = 8) or appendectomy alone (n = 36). All short-term parameters were less favourable for the colectomy group, including higher complication rate, slower return of gastrointestinal function, higher requirement of parenteral analgesic and longer hospital stay. Without colectomy, only 2 patients developed recurrent diverticulitis necessitating hospitalisation, both of whom resolved on conservative treatment. On the other hand, 1 patient required re-operation after colectomy because of intestinal obstruction. The overall re-hospitalisation rate was comparable between the colectomy and the non-colectomy group (16.7% vs. 13.6%). Emergency colectomy can eradicate suspicious lesions and eliminate risk of recurrent diverticulitis but at the expense of higher morbidity rates. As the natural course of uncomplicated right-sided colonic diverticulitis is usually benign, conservative treatment with minimal surgery may be a better therapeutic option.

Objective: This prospective study aimed to evaluate the efficacy and safety of 4% formalin dab in managing patients with refractory radiation proctitis. Methods: From January 2001 to December 2004, 11 patients with radiation proctitis who did not respond to regular steroid enemas and/or argon plasma coagulation were treated with local application of 4% formalin-soaked gauze (formalin dab). Main outcome measures were control of bleeding, changes in haemoglobin level, hospitalization and blood transfusion requirements, and complications. Results: The mean haemoglobin level before formalin dab was 7.3 ± 2.4 g/dL. Eight patients had required repeated admissions to hospital for blood transfusions (median 4 units; range, 2–27 units). The median number of sessions of formalin dab was two (range, 1–6). The treatment was effective in 10 patients (90.9%): four patients had complete cessation of bleeding and six patients had improvement of symptoms. At a median follow-up of 15.3 months, only three patients required hospital admission once for blood transfusions (range 1–2 units). The mean haemoglobin level after formalin dab was 10.4 ± 2.2 g/dL, which was significantly higher than that before formalin dab (P = 0.007). No patient developed complications after formalin dab. Conclusions: Formalin dab is an effective and safe treatment modality for refractory radiation proctitis.

Background: Post-haemorrhoidectomy wound pain is often the focus of concern for patients as well as their clinicians. Despite the recent enthusiasm brought about by stapled haemorrhoidectomy, conventional haemorrhoidectomy still remains the mainstay of surgical treatment for symptomatic third and fourth degree haemorrhoids in places where healthcare funding cannot afford these expensive devices. The present study aims at evaluating the effectiveness of pre-emptive analgesia and oral metronidazole in reducing wound pain and complications after open haemorrhoidectomy. Method: Patients with symptomatic third or fourth degree haemorrhoids undergoing open haemorrhoidectomy were randomized into four groups. Group 1 received pre-emptive analgesia (0.5% bupivacaine). Group 2 received oral metronidazole (400 mg three times daily for 1 week). Group 3 received both treatments while group 4 was the control group. Results: Number of patients recruited was 105. There was no significant difference among the four groups in terms of pain scores on the first three postoperative days, analgesic requirements, hospital stay and the time to return to normal daily activities. Patients who received oral metronidazole had significantly less pain at the time of the first bowel motion (P = 0.037). Conclusion: Oral metronidazole significantly reduces pain during the first bowel motion after open haemorrhoidectomy. Pre-emptive analgesia with 0.5% bupivacaine does not reduce postoperative pain.

We report our preliminary experience in urgent laparoscopically assisted right hemicolectomy for obstructing right-sided colon carcinoma.From January to April 2005, seven consecutive patients with obstructing right-sided colon carcinoma underwent emergency laparoscopically assisted right or extended right hemicolectomy. Patient demographic data, operative details, and short-term clinical outcomes were prospectively collected and analyzed.The median duration of obstructing symptoms prior to admission was 3 days (range, 1-6 days). Two patients underwent palliative resection and five patients underwent curative resection. The median operative time was 180 minutes (range, 125-350 minutes). There were no conversions to the open procedure. Median blood loss was 30 mL (range, negligible-300 mL). The median times to resuming diet, first bowel motion, and full ambulation were 4 days (range, 3-10 days), 5 days (range, 3-7 days), and 4 days (range, 4-5 days), respectively. The median duration of hospital stay was 7 days (range, 6-19 days). One patient with ischemic heart disease developed acute coronary syndrome postoperatively and died on postoperative day 19. The remaining patients had no complications. The median tumor length was 3.5 cm (range, 2-5 cm) and the median number of lymph nodes removed was 17 (range, 16-36).Emergency laparoscopically assisted right hemicolectomy for obstructing right-sided colon carcinoma is feasible and safe, with favorable short-term clinical outcomes and an acceptable number of lymph nodes removed.

Objective: The aim of the present study was to review our experience in the surgical management of patients with obstructing colorectal cancers over an 11-year period, 1987–1997. Patients and methods: Retrospective review of case records of 275 patients (male: 177; female 98) who had undergone emergency surgery for obstructing colorectal cancers was performed. Tumours proximal to splenic flexure were defined as proximal tumours while those at or below the splenic flexure were defined as distal tumours. Results: The obstruction was caused by proximal tumours in 88 (32%) patients. The resection rate and the primary anastomotic rate were higher for proximal tumours compared with distal tumours (95.5%vs 85.6%, P = 0.014; 92%vs 30.5%, P

The proportion of colorectal cancers located proximal to the splenic flexure increases with age. Colorectal cancers of the microsatellite instability phenotype are preferentially located in the proximal colon. We investigated the location of colorectal cancer with this phenotype in different age groups to determine whether different molecular mechanisms could account for the changes in distribution of colorectal cancers.A representative sample of 230 colorectal cancers from three age groups (45 years, 60-70 years,87 years) was selected from a subset of The Upper Midwest Oncology Medical Registries database. Microsatellite instability was determined by polymerase chain reaction using a panel of five microsatellite markers. The presence of new microsatellite alleles at two or more loci was scored as microsatellite instability. Tumors were otherwise considered microsatellite stable. MLH1 and MSH2 expression was determined by immunohistochemistry. Methylation of the MLH1 gene promotor was determined by methylation-specific polymerase chain reaction assay.The proportion of tumors of the microsatellite instability phenotype was 21 percent in the young group, 15 percent in the middle group, and 33 percent in the old group. More tumors of the microsatellite instability phenotype were proximal compared with microsatellite-stable tumors in all three age groups, but the differences were significant only for the old group. Tumors of the microsatellite instability phenotype in the older group were associated with MLH1 inactivation (24/29 or 83 percent), MLH1 promoter methylation (18/29 or 62 percent), and proximal location (25/29 or 86 percent), while tumors in the young group were associated with MSH2 inactivation (8/18 or 44 percent) and distal location (11/18 or 62 percent).The age-related proximal shift of colorectal cancers is associated with the microsatellite instability phenotype, MLH1 inactivation, and MLH1 promoter hypermethylation.

Objective: To study the clinical characteristics, investigations, management and pathology in adult colonic intussusception. Methods: A retrospective study of seven adult patients who were operated on for the diagnosis of colonic intussusception in our department from January 1999 to September 2003 was carried out. The case records of the seven patients were retrieved. Their clinical presentations, investigations, operative records and pathology were studied. Results: The mean age of the patients was 67.4 years. There were four men and three women. Five of the patients presented with chronic non-specific symptoms and the other two patients presented with acute symptoms. Transabdominal ultrasonography (USG) and computed tomography (CT) scan were used for investigation. In the majority of the patients (87.5%), radiological features of intussusception were shown by USG or CT scan. All seven patients underwent laparotomy exploration with bowel resection. Six patients (85.7%) had lead points with definable pathology. Within the lead points, five patients had primary malignant lesions. Conclusion: With more liberal use of imaging techniques, more adult intussusception can be diagnosed before explorative surgery. Ultrasound would be an ideal tool for initial evaluation. In view of the high chance of associated malignancy, adult colonic intussusception should be resected without prior reduction at the time of surgery.

Summary Background Although laparoscopic resection of colorectal carcinoma improves post-operative recovery, long-term survival and disease control are the determining factors for its application. We aimed to test the null hypothesis that there was no difference in survival after laparoscopic and open resection for rectosigmoid cancer. Methods From Sept 21, 1993, to Oct 21, 2002, 403 patients with rectosigmoid carcinoma were randomised to receive either laparoscopic assisted (n=203) or conventional open (n=200) resection of the tumour. Survival and disease-free interval were the main endpoints. Patients were last followed-up in March, 2003. Perioperative data were recorded and direct cost of operation estimated. Data were analysed by intention to treat. Findings The demographic data of the two groups were similar. After curative resection, the probabilities of survival at 5 years of the laparoscopic and open resection groups were 76·1% (SE 3·7%) and 72·9% (4·0%) respectively. The probabilities of being disease free at 5 years were 75·3% (3·7%) and 78·3% (3·7%), respectively. The operative time of the laparoscopic group was significantly longer, whereas postoperative recovery was significantly better than for the open resection group, but these benefits were at the expense of higher direct cost. The distal margin, the number of lymph nodes found in the resected specimen, overall morbidity and operative mortality did not differ between groups. Interpretation Laparoscopic resection of rectosigmoid carcinoma does not jeopardise survival and disease control of patients. The justification for adoption of laparoscopic technique would depend on the perceived value of its effectiveness in improving short-term post-operative outcomes.

Objective: To review the yield and indications of colonoscopy in a surgical unit at the Prince of Wales Hospital, the result of which may help to select future patients for colonoscopy. Method: The records of 869 patients undergoing elective colonoscopy at the Prince of Wales Hospital within an 18-month period were reviewed retrospectively. Exclusion criteria included the following: a personal history of colorectal malignancy or polyps, tumours or polyps detectable on rectal examination or rigid sigmoidoscopy, a positive physical examination suggestive of gastrointestinal malignancies, anaemia or positive faecal occult blood. Results: Per rectal bleeding was the most common indication for colonoscopy. Complete colonoscopy rate was 93.7% and abnormalities were reported in 338 patients. Forty-three patients were found to have cancer whereby age, duration of symptoms, blood mixed with stool and abdominal pain were identified as independent predictive factors. Neoplastic polyps were confirmed in 200 patients. Old age and being male were the only factors predictive of neoplastic polyps. Conclusion: Although the majority of patients present with typical haemorrhoidal bleeding, colonoscopy should be considered seriously for elderly patients, especially those who are male. Chinese Abstract Figure Chinese Abstract.

PURPOSE: An aggressive surgical approach with en bloc resection of involved structures is often possible with anterior rectal cancers that invade adjacent visceral organs, but is rarely possible in tumors that invade the pelvic wall. However, most staging systems include both situations in the same group of T4 rectal cancers. We performed a retrospective study of patients with stage T4 rectal cancer undergoing surgery to assess the influence of different organ involvement on resectability and survival. METHODS: A retrospective review was conducted of 84 patients with T4 rectal cancer treated at the University of Minnesota and affiliated hospitals over a ten-year period. Forty-seven patients (56 percent) were staged for local invasion on the basis of final pathology, 19 (23 percent) on the basis of operative findings, and 18 (21 percent) on the basis of ultrasound images. Patients were divided into two groups, those with or without pelvic wall involvement. Resectability, local control, and overall survival were compared between groups. Survival curves were estimated by the Kaplan-Meier method and compared by log-rank test. Multivariate analysis was performed with Cox proportional and logistic regression. RESULTS: Thirty-one patients (37 percent) had involvement of the pelvic wall, whereas 53 patients (63 percent) had visceral involvement only. All 29 patients with distant metastasis died of their disease. Forty-seven of the 55 patients without distant metastasis underwent tumor resection. Age and pelvic wall involvement were the only two factors independently associated with the probability of resection in logistic regression analysis (P=0.0067 andP=0.037, respectively). The only factor that affected median survival in patients without distant metastasis was tumor resection (49.1 months for resectionvs. 6.1 months for no resection,P=0.017). Patients with visceral involvement had a longer median survival (49.2 months) than those with pelvic wall involvement (13.2 months), but the difference did not reach statistical significance (P=0.058). CONCLUSION: Rectal cancers with pelvic and visceral involvement have different rates of resectability and median survival. These differences should be reflected in the TNM classification system.

Objective To compare the systemic cytokine response in patients after laparoscopic-assisted resection with those after open resection of rectosigmoid carcinoma. Summary background data Laparoscopic resection of colorectal carcinoma is technically feasible, but objective evidence of its benefit is scarce. Systemic cytokines are accepted as markers of postoperative tissue trauma and mediators of the host immune response. Methods Thirty-four patients with rectosigmoid carcinoma, without evidence of metastatic disease and suitable for laparoscopic resection, were randomized to undergo either laparoscopic (n = 17) or conventional open (n = 17) resection of the tumor. Clinical parameters were recorded. Sera were collected before surgery and at appropriate time points afterward and assayed for interleukin-1beta, tumor necrosis factor-alpha, interleukin-6, and C-reactive protein. The primary end points were the cytokine and C-reactive protein levels. Data were analyzed by intention to treat. Results The demographic data of the two groups were comparable. The clinical outcome of both groups was satisfactory, with no surgical deaths and a reasonable complication rate. Both interleukin-1beta and interleukin-6 levels peaked 2 hours after surgery, with the responses in the laparoscopic group significantly less than those in the open group. C-reactive protein levels peaked at 48 hours, and the difference was also statistically significant. Levels of tumor necrosis factor-alpha were not elevated after surgery, and there was no difference between the groups. Conclusions Tissue trauma, as reflected by systemic cytokine response, was less after laparoscopic resection than after open resection of rectosigmoid carcinoma. The difference in the systemic cytokine response may have implications on the long-term survival.

In colorectal resections, rectal stump lavage is commonly performed prior to primary anastomosis for reducing bacterial counts and minimizing the risk of anastomotic recurrence. Being a potent bactericidal and cytotoxic disinfectant, chlorhexidine is frequently chosen as the irrigation solution of choice for such purposes. Despite its widespread use, the potential for developing chlorhexidine allergy is still a major concern due to the ever-rising number of literature reports of hypersensitivity reactions to chlorhexidine in surgical patients. This report illustrates the first reported case of life-threatening chlorhexidine anaphylaxis after its use in rectal stump lavage for colorectal resection. This report serves as a reminder of the potential danger of this “hidden allergen” in clinical practice.

This single-center, prospective, randomized trial was designed to compare the short-term clinical outcome between laparoscopic-assisted versus open total mesorectal excision (TME) with anal sphincter preservation (ASP) in patients with mid and low rectal cancer. Long-term morbidity and survival data also were recorded and compared between the two groups. Between August 2001 and August 2007, 80 patients with mid and low rectal cancer were randomized to receive either laparoscopic-assisted (40 patients) or open (40 patients) TME with ASP. The median follow-up time for all patients was 75.7 (range 16.9–115.7) months for the laparoscopic-assisted group and 76.1 (range 4.7–126.6) months for the open group. The primary endpoint of the study was short-term clinical outcome. Secondary endpoints included long-term morbidity rate and survival. Data were analyzed by intention-to-treat principle. The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with less analgesic requirement (P

En bloc bladder resection is often required for treating colorectal cancer with suspected urinary bladder invasion. Our aim was to review our institutional experience in en bloc resection of locally advanced colorectal cancer involving the urinary bladder over a period of 17 years. The hospital records of 72 patients with locally advanced colorectal cancer who underwent en bloc urinary bladder resection at our institution between July 1987 and December 2004 were retrospectively reviewed. Clinical and oncologic outcomes were evaluated. The mean duration of follow-up was 64.3 months. Genuine tumor invasion into the urinary bladder was confirmed in 34 patients (47%) by histopathology. Forty patients (56%) underwent primary closure of the urinary bladder, while 32 patients (44%) required various kinds of urologic reconstructive procedures. Operative mortality occurred in four patients (6%). The overall postoperative morbidity rate was significantly higher in patients undergoing urologic reconstruction (81% vs. 45%, p = 0.002) when compared to that in patients undergoing primary closure. This was mostly attributable to significantly higher rates of urinary anastomotic leak (21.9% vs. 0%, p = 0.002) and urinary tract infection (50% vs. 18%, p = 0.003) in the urologic reconstruction group. For the 57 patients (79%) who underwent curative resection, the 5-year overall survival rate was 59%, and the local recurrence at 5 years was 15%. Both parameters were not significantly affected by the presence of pathologic bladder invasion or the extent of surgical procedures. En bloc bladder resection for locally advanced colorectal cancer involving the urinary bladder can produce reasonable long-term local control and patient survival.

Laparoscopic colon resection is technically challenging, and conversion to open surgery is sometimes unavoidable. The impact of conversion may vary among different types of colorectal resection and pathology. Our present study aims at evaluating the risk factors and clinical outcomes of conversion in laparoscopic resection for right colon cancer.Between the periods April 1992 to July 2007, 183 consecutive patients undergoing laparoscopic-assisted right colon resection for carcinoma of colon were identified from our database. Data pertaining demographic information, operative details, postoperative course, complications, length of stay, 30-day mortality, and follow-up status were analyzed.The overall conversion rate was 12% (22 patients). Stage IV disease, tumor length5 cm, and surgery performed in an earlier time period (before year 2002) were independent risk factors for conversion. Although the median operative time was comparable (195 vs 180 min, p = 0.074), more blood loss was recorded among the conversion group (350 vs 20 ml, p0.001). Conversion was also associated with higher wound infection rate (27.3% vs 5%, p = 0.002) and 30-day mortality (9.1% vs 0.62%, p = 0.039). After potential curative resection, the 5-year overall survival rate of the conversion and no conversion group was 53.8% and 72.6%, respectively (p = 0.039).Our results showed that conversion increased the intraoperative blood loss, wound related morbidities, and the 30-day mortality. Moreover, it had negative impact on overall survival.

PURPOSE: We have previously reported the five-year results of a randomized trial comparing laparoscopic and open resection for cancer of the upper rectum and rectosigmoid junction. The aim of this follow-up study is to report on the long-term morbidity and ten-year oncologic outcomes among the subgroup of patients with upper rectal cancer. METHODS: From September 1993 to October 2002, 153 patients with upper rectal cancer were randomly assigned to receive either laparoscopic-assisted (n = 76) or open (n = 77) anterior resection. Patients were last followed up in December 2007. Long-term morbidity, survival, and disease-free interval were prospectively recorded. Data were analyzed by intention-to-treat principle. RESULTS: The demographic data of the two groups were comparable. More patients in the open group developed adhesion-related bowel obstruction requiring hospitalization (P = 0.001) and intervention. The overall long-term morbidity rate was also significantly higher in the open group (P = 0.012). After curative resection, the probabilities of cancer-specific survival at ten years of the laparoscopic-assisted and open groups were 83.5 percent and 78.0 percent, respectively (P = 0.595), and their probabilities of being disease-free at ten years were 82.9 percent and 80.4 percent, respectively (P = 0.698). CONCLUSION: Laparoscopic-assisted anterior resection for upper rectal cancer is associated with fewer long-term complications and similar ten-year oncologic outcomes when compared with open surgery.

The aim of the present study was to compare the clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for obstructing right-sided colonic carcinoma.Between July 2003 and July 2006, 43 consecutive patients with obstructing right-sided colonic carcinoma underwent emergency right hemicolectomy at our institution, 14 with the laparoscopic-assisted approach and 29 with the open approach. Clinical data were retrospectively recorded and compared between the two groups.There were no significant differences between the two groups with respect to age, gender, co-morbidities, duration of obstructing symptoms, tumor length, and tumor staging. The laparoscopic-assisted group had longer operative time than the open group (187.5 min versus 145 min; p=0.034) but less blood loss (20 ml versus 100 ml; p=0.020). The median time to full ambulation was significantly shorter in the laparoscopic-assisted group (4 days versus 6 days; p=0.016), but the time to return of gastrointestinal function and the duration of hospital stay were similar between the two groups. More patients in the open group developed postoperative complications (55.2% versus 28.6%), but the difference was not statistically significant.Emergency laparoscopic-assisted right hemicolectomy for obstructing right-sided colonic carcinoma is feasible and safe. In comparison with the open approach, the laparoscopic-assisted procedure is associated with less blood loss, earlier ambulation, and possibly lower morbidity rate.

Telerobotic surgery is the most advanced development in the field of minimally invasive surgery. The da Vinci surgical system, which is currently the most widely used telerobotic device, was approved by the Food and Drug Administration of the United States of America for clinical use in all abdominal operations in July 2000. The first da Vinci surgical system in China was installed in November 2005 at our institution. We herein report the first telerobotic-assisted laparoscopic abdominoperineal resection using the 3-arm da Vinci surgical system for low rectal cancer in Hong Kong and China, which was performed in August 2006. The operative time and blood loss were 240 min and 200 mL, respectively. There was no complication, and the patient was discharged on postoperative day five. An updated review of published literature on telerobotic-assisted colorectal surgery is included in this report, with special emphasis on its advantages and limitations.

Ever since its earliest reports, portal venous gas (PVG) has been associated with numerous intraabdominal catastrophes and has served as an indication for urgent surgical exploration. It is traditionally regarded to be an ominous finding of impending death, with highest mortality reported in patients with underlying bowel ischemia. Today, computed tomography has demonstrated a wider range of clinical conditions associated with PVG, some of which are "benign" and do not necessarily require surgery, unless when there are signs of intraabdominal catastrophe or systemic toxicity. One of these "benign" conditions is Crohn's disease. The present report describes a 19-year-old Chinese boy with Crohn's pancolitis who presented with septic shock associated with PVG and portal vein thrombosis, and was successfully managed surgically. To our knowledge, this is the first report of PVG and portal vein thrombosis associated with Crohn's disease in a Chinese patient. In addition, we have also reviewed the reports of another 18 Crohn's patients with PVG previously described in the English literature. Specific predisposing factors for PVG were identified in 8 patients, including barium enema, colonoscopy, blunt abdominal trauma, and enterovenous fistula. The patients who developed PVG following barium enema and blunt trauma were all asymptomatic and no specific treatment was necessary. Eleven patients (58%) who presented with signs of intraabdominal catastrophe or systemic toxicity required either immediate or eventual surgery. The overall mortality rate among the 19 patients was only 11%. The present literature review has shown that the finding of PVG associated with Crohn's disease does not always mandate surgical intervention. It is the clinical features and the related complications that ultimately determine the treatment approaches. The overall outcome of PVG associated with Crohn's disease has been favourable.

Simultaneous resection of colorectal tumor and liver metastasis has been advocated because of the benefits of avoiding a second operation, reduced morbidity, shorter treatment time, and similar outcomes. We report a case of simultaneous laparoscopic resection. The operative time was 350 minutes and the estimated blood loss was 500 mL. The patient required parenteral analgesia for less than 48 hours. Flatus was passed on postoperative day 3, and a solid diet was resumed on postoperative day 5. He was fully mobile on postoperative day 4 and was discharged 3 days later. With the advance of laparoscopic technology and technique, simultaneous resection becomes an attractive option.

Colorectal self-expandable metal stents (SEMS) have been used successfully as preoperative bridges to surgery for obstructive left-sided colorectal carcinoma. Endoscopic relief of the obstruction allows for full bowel preparation and accurate preoperative staging. A laparoscopic approach, considered by many to be contraindicated in the presence of obstruction, becomes feasible after endoscopic decompression. We present a case of obstructive carcinoma of the descending colon successfully treated with endoscopic decompression with colorectal SEMS. Subsequent staging with computed tomography revealed a renal cell carcinoma in the left kidney. Synchronous laparoscopic resection of the two carcinomas was performed, with no morbidity. To the best of our knowledge, this is the first report of endolaparoscopic left hemicolectomy and synchronous laparoscopic radical nephrectomy for obstructive carcinoma of the descending colon and renal cell carcinoma. The advantages of colorectal SEMS and the endolaparoscopic approach in managing obstructive colorectal carcinoma are discussed.

No previous report could be found in the literature comparing laparoscopic and open total colectomy for colorectal cancers, especially synchronous colorectal cancers. This study aimed to compare the short-term clinical outcomes and oncologic results of laparoscopic and open total colectomy or proctocolectomy for colorectal cancers. Between July 1997 and January 2005, six patients with colorectal cancers underwent elective laparoscopic total colectomy or proctocolectomy at the authors’ institution. Clinical data for 12 patients who underwent elective open total colectomy or proctocolectomy for colorectal cancers during the same period were prospectively collected and compared. The median follow-up periods were 43.9 months for the laparoscopic group and 48.2 months for the open group. Conversion to open procedure was required for one patient (16.7%) in the laparoscopic group because of bleeding. The median operative time was significantly longer in the laparoscopic group (427.5 min; range, 280–480 min vs 172.5 min; range, 90–260 min; p = 0.001). The patients in the laparoscopic group required a significantly shorter duration of parenteral analgesia (3 vs 5 days; p = 0.01), but there were no differences in time to first bowel motion, time to resumption of diet, time to full ambulation, and duration of hospital stay between the two groups. Perioperative morbidity rates were comparable between the two groups, and there was no operative mortality. The oncologic results, including number of lymph nodes removed, recurrence rates, and survival rates, were similar in the two groups. Laparoscopic total colectomy has short-term clinical outcomes (postoperative recovery and perioperative morbidity and mortality rates) and oncologic results similar to those of open surgery for treating patients with colorectal cancers. Our study has shown that the only advantage of laparoscopic over open surgery is a shorter duration of analgesic requirement, but at the expense of a longer operative time.

Background: Liver abscess is commonly biliary in origin. We assessed the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with pyogenic liver abscesses. Methods: Between January 1986 and December 1997, 63 patients with pyogenic liver abscesses were referred for ERCP. Twenty-one patients had a history of previous biliary procedures including cholecystectomy (21), biliary-enteric bypass (9), surgical sphincteroplasty (5), and endoscopic sphincterotomy (2). Demographic data, clinical features, biochemical parameters, treatment, clinical progress, and follow-up were recorded and analyzed. Results: Two patients required laparotomy and 61 patients underwent guided aspiration and/or drainage at a median interval of 3 days after presentation. ERCP was performed at a median of 8 days (range 1 to 69 days) after initial treatment and succeeded in 90% of cases with no associated complication or death. Abnormalities were shown in 29 (46%) patients: biliary obstruction due to stones or strictures (15), ductal dilatation alone (7), spontaneous choledochoduodenal fistula (3), communication between abscesses and biliary tree (3), and splaying of biliary ducts by space-occupying effect (2). No abnormality was found in 34 patients. Eight patients underwent endoscopic therapy including sphincterotomy (5), stone extraction (6), and nasobiliary drainage (2). Overall mortality rate from liver abscesses was 6%. Conclusions: ERCP is useful in the treatment of patients with pyogenic liver abscesses. (Gastrointest Endosc 1999;50:340-4.)

INTRODUCTION: The place of laparoscopic-assisted colectomy for colorectal carcinoma is controversial. This study reviewed a consecutive series of patients who underwent laparoscopic-assisted resection of colorectal carcinoma in the past five years. METHODS: Two hundred seventeen laparoscopic-assisted resections of colorectal carcinoma were attempted starting in April 1992. Initially, we only selected patients with metastatic disease or patients who were older than 65 years. Subsequently, both palliative and curative resections were attempted in patients with a suitable tumor, with no age limitation. Thus, all suitable patients were randomly assigned to received either laparoscopic-assisted or conventional open surgery. RESULTS: Data collection was completed in 201 patients. In 22 patients open surgery was performed after a diagnostic laparoscopy. In the remaining 179 patients (90 males) in whom laparoscopic dissection was actually performed, the mean follow-up was 19.8 months, and the mean age was 66.3 years. The procedures performed included right hemicolectomy or extended right hemicolectomy (30 patients), transverse colectomy (2 patients), left hemicolectomy (3 patients), sigmoidectomy (48 patients), anterior resection (59 patients), and abdominoperineal resection (37 patients). Thirty-two (17.7 percent) procedures were converted to open surgery. The mean operation time was 203 minutes. The median blood loss was negligible, and the median requirement of transfusion was zero. The median number of postoperative parenteral analgesic injections was three. The median time to resume diet and hospital discharge were four and six days, respectively. The operative mortality was 1.7 percent. The survival rates at four years were 100, 88.3, and 64.5 percent for patients with Dukes A, B, and C disease, respectively. There was only one (0.65 percent) port-site recurrence. CONCLUSION: Laparoscopic-assisted resection of colorectal carcinoma was technically feasible and safe. It allowed early postoperative recovery with satisfactory long-term survival. This is at the expense of a long operation. Its benefits over the conventional open technique await the results of the randomized trials.

The retrieval of spleen after laparoscopic splenectomy has long been a problem. Frequently, it is necessary to extend the wound for retrieving the spleen intact and to prevent potential spillage of splenic tissue into the peritoneal cavity. We describe the application of the liposuction unit to remove the spleen piecemeal after laparoscopic splenectomy. We have found this technique easy to apply and safe, without the necessity of excessive wound extension, while preserving splenic tissue for histologic examination.

Aim: The aim of this study was to compare the operative and short-term clinical outcomes of emergency laparoscopic-assisted versus open right hemicolectomy for complicated caecal diverticulitis. Methods: Between September 2001 and June 2006, 18 consecutive patients with complicated caecal diverticulitis underwent emergency right hemicolectomy at out institution, six with the laparoscopic-assisted approach and 12 with the open approach. Clinical data were prospectively recorded and compared between the two groups. Results: There were no significant differences between the two groups with respect to age, gender, comorbidities, duration of symptoms, and Hinchey staging. There was no conversion in the laparoscopic-assisted group. Compared to the open group, the laparoscopic-assisted group had a slightly longer operative time (167.5 vs 150 min, P = 0.083) but significantly less blood loss (35 vs 100 mL, P = 0.041). Although the median time to first bowel motion was significantly shorter in the laparoscopic-assisted group (3 vs 5 days, P = 0.041), the time to full ambulation and the duration of hospital stay were similar between the two groups. The postoperative complication rates (50% vs 33.3%), as well as the hospital readmission rates for complications (33% vs 0%), were higher in the open group than the laparoscopic-assisted group, but the differences did not reach statistical significance. Conclusion: Emergency laparoscopic-assisted right hemicolectomy for complicated caecal diverticulitis is feasible and safe in the hands of experienced surgeons. Compared with the open approach, the laparoscopic-assisted approach is associated with less blood loss and earlier return of gastrointestinal function.

The increase in the incidence of colorectal cancer (CRC) is higher for proximal than for distal tumors. As microsatellite instability (MSI) is a feature of proximal tumors, we hypothesize that an increase in MSI tumors may account for the age-related proximal shift in CRC. Methods: A representative sample of 230 CRCs from 3 age groups was selected from a CRC database. MSI was determined by PCR. MLH1 and MSH2 expression was determined by immunohistochemistry, and the methylation of the MLH1 gene promotor (PM) by methylation-specific PCR. Results: MSI tumors became more frequent (p < 0.01 chi square) and more proximal in distribution (p = 0.01 loglinear) in the oldest age group. MSI was associated with loss of expression of MSH2 in the young age group. PM and inactivation of MLH1 increased with age. Conclusion: MSI tumors became more frequent and proximal in older patients. This trend was associated with differences in the underlying mechanisms responsible for the MSI phenotype.