Laparoscopic colon resection: Experience from a community hospital

Background
Laparoscopic colon resection (LCR) is a well-documented and standard practice in many centres throughout the world. A Cochrane Collaboration review of 25 randomized control trials published in 2005 analyzed the short-term (30-day) benefits of LCR compared with open surgery, and demonstrated better outcomes in intraoperative blood loss, intensity of postoperative pain, postoperative hospital stay, duration of postoperative ileus, and pulmonary function.[1] Total morbidity and local (surgical) morbidity were reduced in the LCR groups. 

Until the 30th postoperative day, quality of life was also better for LCR patients. The Cochrane reviewers concluded that if the long-term oncological results of laparoscopic and conventional resection prove to be equivalent, “the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.”

Another Cochrane review published in 2008 looked at 33 trials comparing laparoscopic or laparoscopic-assisted colectomy and open colectomy for colorectal carcinoma. The trials found similar long-term outcomes in both groups.[2] Four major studies (Barcelona trial, COST, COLOR, MRC-CLASSIC)[3-6] showed no difference in the survival, recurrence of tumor, resection margin, or lymph node harvest for both total number and number of positive nodes. The overall conversion rate from laparoscopic to open surgery for these four trials was 19% (range 11% to 25%). While the results showed a significant increase in operating room time for LCR when compared with open colon resections, they also showed a reduction in duration of hospital stay.

The 2006 UK NICE review[7] confirmed findings about operating time and hospital stay, and showed a decreased frequency of early complications and 30-day mortality. As well, the UK NICE review found there was a tendency to harvest fewer lymph nodes and an increased risk of anastomotic leakage, although these findings did not reach statistical significance. (It should be noted that the National Cancer Institute[8] has set a minimum standard of 12 nodes for resection, and the American College of Surgeons has suggested a resection of 15 lymph nodes improves cancer survival in colon cancer.[9])

Based on the research findings described here, we hypothesized that surgical outcomes would be similar whether LCR was performed at a community hospital or at a university hospital. By gathering data from a BC community hospital to compare with findings published in the surgical literature, we sought to determine whether outcomes were equivalent in terms of safety (intraoperative and postoperative complications), surgical oncology technique (resection margins, lymph node count), operating time, conversion rate, and duration of hospital stay.

Methods
Office notes, hospital electronic records, and operating room records were used to conduct a retrospective analysis of outcomes for LCR performed by four surgeons at Chilliwack General Hospital from June 2005 to June 2010. 

Cases selected for study included patients who received laparoscopic colectomy in the 5-year study period. Emergency surgery patients were excluded. 

Microsoft Excel was used for collection and basic analysis of data. Demographic, operative, and postoperative data were summarized and reported as counts and percentages for categorical variables and as mean/median/range for continuous variables. 

Results 
From June 2005 to June 2010, laparoscopic colon resection was performed on 136 patients (53% male) at Chilliwack Hospital. Patients ranged in age from 20 to 90 (mean 68 years) and exhibited the disease characteristics summarized in Table 1. Image-based preoperative and postoperative TNM staging results were obtained for patients with malignant disease, as shown in Table 2. The surgeons involved in the study attended LCR courses to upgrade their skills and also invited an expert surgeon from a tertiary hospital to demonstrate hand-assisted LCR. (In the end, the hand-assisted technique was not adopted by any of the surgeons, who continued using the standard four-ports LCR technique and improved their skills by assisting each other.) 

The surgeons performed 78 right, 42 sigmoid, 5 left, 2 subtotal, 1 transverse, and 1 segmental colon resection, as well as 6 anterior resections. In 29 cases (21%), conversion from laparoscopic to open surgery was necessary. Intra-abdominal adhesions led to conversion in 17 cases (59%). Other reasons for conversion are shown in Table 3, while early and late complications for the procedure are shown in Table 4. Late complications include only those reported by patients who sought medical attention. Patients were routinely followed for 4 weeks in the postoperative period, unless they had complications or surgical issues that required ongoing care. In addition to these complications, there were five deaths in the postoperative 30-day period. Two were secondary to cardiovascular events (pulmonary embolism and stroke), one patient died at home after a fall and broken hip, and two patients died as a result of intra-abdominal sepsis (abscess and duodenal perforation).

Other data collected indicate that the mean operating time for the first 68 cases was 132 minutes (range 60 to 245), and that for the remaining 68 cases it was 106 minutes (range 27 to 205). The radial margins were clear in 100% of cancer cases, and the mean number of lymph nodes harvested was 13.2 (median 13). All findings were compared with the results of other benchmark studies, as shown in Table 5. 

Conclusions
The results of our study are similar to those of major trials of laparoscopic colon resection for colon cancer, and of two other studies from community hospitals in British Columbia and Washington state.10,11 Our lymph node harvest numbers were higher than in any study published to date. The mortality rate in our study was similar to mortality rates in other studies, although only two of the five deaths were related to surgical complications. 

Our study adds to the limited data available showing that LCR can be introduced and performed in community hospitals with surgeons who are already performing minimally invasive surgical procedures. With tighter resource allocation and reduced operating room time, many surgeons are concerned that laparoscopic colectomy is more time-consuming than open technique. In our experience, the operating time was not excessive and did not make an impact on operating room use. We believe that the excessive time reported for laparoscopic colon resection in the major published trials may represent the added time surgeons in the trials spent learning. The majority of those trials were conducted when laparoscopic colon surgery was being introduced into wider surgical practice. This is also confirmed by our data, which show an average reduction of 26 minutes in operating time during the second half of the study period. 

Overall, our findings confirm that outcomes for laparoscopic colon resection performed at a community hospital are similar to results described in the literature, and that laparoscopic technique can be safely introduced and performed at a community hospital.

Competing interests
None declared.

Dr Khan is a resident in general surgery at the University of British Columba. Drs Schwarz, McDonald, Causton, and Wiggins are staff surgeons at Chilliwack General Hospital. The authors presented the findings in this article at the Annual Spring Meeting of the BC Surgical Society, May 2011, in Parksville, BC.