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Original Article |

Laparoscopy Decreases Anastomotic Leak Rate in Sigmoid Colectomy for Diverticulitis FREE

Melissa Levack, MD; David Berger, MD; Patricia Sylla, MD; David Rattner, MD; Liliana Bordeianou, MD
[+] Author Affiliations

Author Affiliations:Colon and Rectal Surgery Program, Division of GastrointestinalSurgery, Massachusetts General Hospital and Harvard Medical School,Boston, Massachusetts.


Arch Surg. 2011;146(2):207-210. doi:10.1001/archsurg.2010.325.
Text Size: A A A
Published online

Background  Early studies comparing laparoscopic and open operations for diverticulitis failed to show any advantages of the laparoscopic approach. Our study compared the 30-day postoperative outcomes of laparoscopic and open sigmoid colectomy for diverticulitis by surgeons who had performed 20 or more laparoscopic colectomies before the study period.

Hypothesis  Patients who undergo an electivelaparoscopic operation for diverticulitis have reduced postoperativecomplications compared with patients who have a traditional openoperation.

Design  Retrospectiveanalysis.

Setting  Academic medicalcenter.

Patients  A total of 249patients who underwent elective open (n = 127) orlaparoscopic (n = 122) sigmoid colectomy with primaryanastomosis for diverticulitis between July 1, 2001, and February 1,2008.

Main Outcome Measures  Combined rates of free and contained anastomotic leaks. A logisticregression model was used to determine predictors of anastomoticleaks while controlling for significant differences between studygroups.

Results  Patients whounderwent laparoscopic or open operations were similar in age, sex,history of diagnosed intraabdominal abscess (9.4% vs 12.3%), andhistory of preoperative percutaneous abscess drainage (3.9% vs 4.9%).Patients who underwent the open procedure had a higher Charlsoncomorbidity index (1.6 vs 1.2; P = .04), and those wh underwentlaparoscopy more frequently underwent splenic flexure mobilization(82.8% vs 26.7%; P < .001).Patients who underwent a laparoscopy had lower rates of anastomoticleaks (2.4% vs 8.2%; P = .04).This finding held true on logistic regression analysis (odds ratio, 0.67; 95% confidence interval, 0.008-0.567; P = .01), even when controlling for age,Charlson comorbidity index, splenic flexure mobilization, and lengthof resected bowel.

Conclusion  Anastomotic leaks occurred less frequently after laparoscopicsigmoid colectomy performed by experienced laparoscopic colorectalsurgeons.

Diverticulitis remains a commondisease with a rising incidence in Western society.1 Today, most attacks ofdiverticulitis can be managed without surgical intervention asantibiotic efficacy, percutaneous drainage, and diagnostic modalitiesimprove.2,3As a result of the increase in nonoperative management, theindications for elective colectomy for diverticulitis have evolved as well. Infrequently, patients may still need traditional laparotomiesand colostomies to treat perforated feculent peritonitis. Far morecommonly, however, patients undergo elective procedures to preventfuture trips to the emergency department, minimize pain associatedwith attacks, and reduce anxiety associated with developing furtherattacks of diverticulitis.4,5 The timing for elective operations for thesepatients, however, is a matter of heated debate.3,5

Concomitant with theshift toward a more nonoperative approach to the treatment ofdiverticulitis, the surgical community is also witnessing rapidadvancement in the development of laparoscopy. Since the firstdescription of laparoscopic colectomy in 1991,6 numerous authors have published reports on theadvantages of laparoscopic colectomy for diverticular disease.714 These and other studies documented multipleshort-term benefits in patients who underwent laparoscopiccolectomies, including shortened length of hospital stay, fewer wound infections, decreased pain, and better pulmonary function.15,16 On the otherhand, investigators have not been able to show significantdifferences in the rates of serious complications such as deaths,anastomotic leaks, and reoperations—nor were they able to showany long-term advantages of laparoscopy.7,14,17,18

Open sigmoid colectomy remains thecriterion standard for the surgical approach for patients with priorattacks of diverticulitis; however, this assertion has recently beenchallenged.19 Informationconcerning 8660 patients who underwent either open or laparoscopiccolectomies were entered into the database maintained by the AmericanCollege of Surgeon's National Surgical Quality Improvement Program(NSQIP). A review of these data found that laparoscopy for abdominalcolectomy decreased overall complications as well as individualcomplications, independent of the NSQIP morbidity probabilitystatistic, which is an NSQIP method for estimating a patient's riskfor postoperative complications based on that patient's preoperativecomorbidities.20 Inaddition, the authors found a significant increase in wound andseptic complications in the open colectomy group. However, becausethe NSQIP database only documents deep infections in general, thisstudy was hindered by its inability to report one of the mostimportant complications pertinent to colorectal operations,specifically, the rate of anastomotic leaks. The authors also wereunable to report how many patients required diversion or how manypatients never received an anastomosis. Furthermore, their data contradicted the results of several randomized controlled studiesthat claim that laparoscopic and open techniques have similarpostoperative outcomes.21,22

The purpose of this study was tosystematically compare the 30-day postoperative outcomes oflaparoscopic vs open sigmoid colectomies performed by surgeons whohad completed 20 or more laparoscopic colectomies before the study period. Our goal was to test the hypothesis that patients whounderwent elective laparoscopic sigmoid colectomy for diverticulitishave reduced postoperative complications compared with patients whohad traditional open sigmoid colectomy.

PATIENTS

Our study population consisted of 249patients who underwent elective laparoscopic or open sigmoidcolectomy with primary anastomosis from July 1, 2001, throughFebruary 1, 2008, by 1 of 9 surgeons at the Massachusetts GeneralHospital. These patients were identified from the MassachusettsGeneral Hospital medical records database using the Research PatientDatabase Query tool to identify patients who underwent partialcolectomy for the diagnosis of diverticulitis using theInternational Classification of Diseases, NinthRevision23 procedure code 562.11.The initial search generated 421 results. Theseelectronic records were then individually reviewed and 172 patientswere excluded because their operation was miscoded and they underwenta subtotal colectomy, diverticulitis was not the indication for surgical intervention, intestinal continuity had not been restored,or the operation was not performed on an elective basis. Theremaining 249 patients became our study population. Diverticulitis ofthe sigmoid colon was diagnosed in these patients based on the results of computed tomography imaging, and the disease wasconsidered asymptomatic at the time they were admitted for theirelective colectomy. Their medical records were then carefullyreviewed to document sex, age, comorbidities, preoperativemddications, preoperative disease history (eg, number of attacks ofdiverticulitis before resection, number of attacks with associatedabscesses, and number of attacks requiring percutaneous drainage),details of the ultimate operative procedures, and postoperativerecovery and complications. The age-adjusted Charlson comorbidityindex, initially developed in 1987 and extensively used in theliterature to demonstrate predictive validity for risk of mortality,24,25 was calculated for each patient based on dataollected for preexisting comorbidities.

Our primary end point was the cumulative rate of postoperative complications within 30 days after the surgical procedure, including anastomotic leaks; postoperative wound infections; early small-bowel obstructions; cardiac (myocardial infarction or cardiac arrest), renal (rise in serum creatinine or new dialysis requirement), pulmonary (acute respiratory distress syndrome or respiratory distress requiring intubation), or neurologic (stroke or paralysis) complications; postoperative sepsis; reexploration in the operating room; intraabdominal abscess diagnosed by computed tomography scan; or readmission. We defined anastomotic leaks based on the criteria established by Damrauer et al.26Free leaks were defined as diffuse gross contamination of the peritoneal cavity (peritonitis) as demonstrated on computed tomography scan or in the operating room during a reexploration. Contained leaks were defined as localized perianastomotic collections that demonstrated communication with the gastrointestinal lumen during their percutaneous drainage or during reexploration.

STATISTICAL ANALYSIS

All statistical analysis was completed using SAS software (SAS Institute, Inc, Cary, North Carolina). Categorical variables are reported as percentages and frequencies; continuous variables are reported as mean (SD). We used intention-to-treat analysis to compare other differences between the groups, such as demographic factors, medical comorbidities, and ultimate surgical outcomes, using Fisher exact test, χ2 test, or t test, as appropriate. Finally, a multivariate logistic regression model was fitted to determine predictors of anastomotic leaks while controlling for differences identified on univariate analysis. P < .05 was considered statistically significant.

One hundred twenty-seven patients underwent elective laparoscopic sigmoid colectomy and 122 patients underwent elective open sigmoid colectomy. Twenty-two patients (17.3%) who underwent a laparoscopic procedure eventually needed an open operation. The decision to convert was made at the discretion of the surgeon at the time of operation. Reasons for conversion included extensive adhesions, bleeding, and failure to visualize the ureter.

Patients who underwent laparoscopy were similar to those who had the open procedure in age, sex, history of intra-abdominal abscess during their prior episode of diverticulitis, or history of abscess requiring percutaneous drainage before the operation. However, patients who underwent open sigmoid colectomy had a higher Charlson comorbidity index (Table 1).

Table Graphic Jump LocationTable 1. Comparison of Patients Undergoing Laparoscopic vs Open Sigmoid Colectomy by Preoperative Factors

Intraoperatively, patientsundergoing laparoscopy were 4 times more likely to have a splenicflexure mobilization (82.8% vs 26.7%; P < .001) and nearly 5 times morelikely to have a double-stapled end-to-end anastomosis instead of anextracorporeal handsewn anastomosis (91.8% vs 21.3%; P < .001). However, the length of colon resection, derived from the pathology report (19.9 cm vs 19.1 cm), and the need for a diverting ileostomy (0.4% vs 0.1%) were similar.

Ultimately, on univariate analysis, our 30-day postoperative outcomes were largely similar between groups (Table 2). Patients had similar rates of wound infections, early small-bowel obstructions, ileus, and renal and cardiac complications. However, patients who underwent laparoscopy had lower rates of anastomotic leaks and intra-abdominal infections.

Table Graphic Jump LocationTable 2. Comparison of Postoperative Complications: Univariate Analysis

These differences held true on multivariate logisticregression analysis. Patients who underwent laparoscopy had a statistically significant decrease in their rates of anastomoticleaks compared with those who had the open procedure (odds ratio[OR], 0.67; 95% confidence interval, 0.008-0.567;P = .01), even when controlling for age (OR, 1.11; P = .90), Charlson comorbidity index (OR, 0.67; P = .20), splenic flexure takedown (OR, 0.94; P = .40), and length of resected bowel (OR,  0.94; P = .90).

Numerous studies2731 have shown laparoscopic colon operations to be equivalent to open operations in terms of safety profile, while also offering patients the advantage of shorter lengths of hospital stay, smaller incisions, less pain, and quicker return to full activity. Our data, taken together with the NSQIP database, challenge this assertion that postoperative complication rates are equivalent across surgical techniques.

Fortunately, anastomotic leaks are uncommon, but they are a serious complication after colectomy. On average, the occurrence of anastomotic leaks after sigmoid resection is between 0% and 8.2%.15,16,32,33 Unfortunately, this means that surgical studies are either underpowered to detect differences in leak rates between competing surgical techniques or the incidence of leaks is underreported because authors fail to accurately establish a precise definition for their criteria for postoperative anastomotic leak. For example, a study by Dwivedi et al15 described 66 patients who underwent laparoscopic sigmoid colectomy and 88 patients who underwent open sigmoid colectomy for diverticulitis. One patient (1.5%) in the laparoscopic group had an anastomotic leak compared with 3 patients (3.4%) in the open group. The authors concluded that the rates of postoperative complications (including all subsets) were similar. A study by Hinojosa et al32 comparing 7239 patients who underwent sigmoid colectomy for benign disease reported a nearly equal leak rate (0.7% vs 0.8%) in their series. Although this was a very large study, the authors did not comment on their criteria for defining anastomotic leaks. Kasparek et al16 and Faynsod et al33 reported no occurrences of anastomotic leaks in either group in their series, with both including 20 patients.

In our study, we defined anastomotic leaks in a more rigorous fashion. Patients were considered to have had an anastomotic leak if they had peritonitis requiring reexploration and if they had a postoperative abscess near their anastomosis, with communication to the anastomosis proved upon injection of contrast medium into the abscess cavity. Using this more precise definition, we were able to show that the laparoscopic procedure is superior to the open procedure in important postoperative outcomes. We found an 8.2% rate of anastomotic leaks in patients who underwent open colectomies. Patients who underwent laparoscopy had only a 2.4% rate of anastomotic leaks. Interestingly, the rates of leaks requiring reexplorations were similar between the 2 arms.

Our data have some limitations. Patients selected for laparoscopy may differ from those who are offered an open operation. As seen in our cohort, patients offered laparoscopy tended to be healthier; their Charlson comorbidity index was significantly lower. We attempted to control for differences that we could measure (ie, body mass index, age, sex, and comorbidities); however, subtle differences between the 2 groups might have been missed. Although the Charlson comorbidity index is not the ideal tool to control for comorbidities in this study population, we opted to use it given that it was the best validated instrument that we could find. Nevertheless, we believe that this study, along with the NSQIP database, supports the argument that laparoscopic sigmoid colectomy is associated with lower morbidity and may become a preferred approach for patients who are candidates for elective laparoscopic procedures.

Anastomotic leaks are less common after elective laparoscopic sigmoid resection than open sigmoid resection. Although patients treated with open operations had more comorbidities, the rate of anastomotic leaks remained higher in that group even when these differences were accounted for. Based on our study results, as well as the large NSQIP database, laparoscopic sigmoid resection is associated with lower morbidity.

Correspondence: Liliana Bordeianou, MD, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman St, Bldg ACC 460, Boston, MA 02114 (lbordeianou@partners.org).

Accepted forPublication: January 25, 2010.

AuthorContributions:Study concept and design: Levack, Berger, and Bordeianou. Acquisition of data: Levack, Sylla, and Bordeianou. Analysis and interpretation of data: Levack, Rattner, and Bordeianou. Drafting of the manuscript: Levack, Rattner, and Bordeianou. Critical revision of the manuscript for important intellectual content: Levack, Berger, Sylla, and Bordeianou. Statistical analysis: Bordeianou. Administrative, technical, and material support: Levack, Sylla, Rattner, and Bordeianou. Study supervision: Berger, Rattner, and Bordeianou.

Financial Disclosure: None reported.

Previous Presentations: This study was presented as a poster at the 50th Annual Meeting of the Society for Surgery of the Alimentary Tract; June 1, 2009; Chicago, Illinois; and at the 56th Annual Meeting of the Massachusetts Chapter of the American College of Surgeons; December 5, 2009; Boston, Massachusetts.

Kang  JYHoare  JTinto  Aet al   Diverticular disease of the colon—on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000. Aliment PharmacolTher 2003;17 (9) 1189- 1195
PubMed
Ambrosetti  PJenny  ABecker  CTerrier  TFMorel  P Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000;43 (10) 1363- 1367
PubMed
Rafferty  JShellito  PHyman  NHBuie  WDStandards Committee of American Society ofColon and Rectal Surgeons, Practice parametersfor sigmoid diverticulitis. Dis ColonRectum 2006;49 (7) 939- 944
PubMed
Janes  SEMeagher  AFrizelle  FA Managementof diverticulitis. BMJ 2006;332 (7536) 271- 275
PubMed
Bordeianou  LHodin  R Controversiesin the surgical management of sigmoid diverticulitis. J Gastrointest Surg 2007;11 (4) 542- 548
PubMed
Jacobs  MVerdeja  JCGoldstein  HS Minimallyinvasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1 (3) 144- 150
PubMed
Köckerling  FSchneider  CReymond  MA  et al. Laparoscopic Colorectal Surgery Study Group, Laparoscopic resection of sigmoid diverticulitis:results of a multicenter study. SurgEndosc 1999;13 (6) 567- 571
PubMed
Berthou  JCCharbonneau  P Electivelaparoscopic management of sigmoid diverticulitis. Results in aseries of 110 patients. Surg Endosc 1999;13 (5) 457- 460
PubMed
Perniceni  TBurdy  GGayet  BDubois  FBoudet  MJLevard  H [Results of elective segmental colectomy done withlaparoscopy for complicated diverticulosis]. Gastroenterol Clin Biol 2000;24 (2) 189- 192
PubMed
Smadja  CSbai Idrissi  MTahrat  M  et al.  Elective laparoscopic sigmoid colectomy fordiverticulitis: results of a prospective study. Surg Endosc 1999;13 (7) 645- 648
PubMed
Siriser  F Laparoscopic-assisted colectomy fordiverticular sigmoiditis. A single-surgeon prospective study of 65patients. Surg Endosc 1999;13 (8) 811- 813
PubMed
Slim  KPezet  DStencl  J  Jr  et al.  Prospective analysis of 40 initial laparoscopiccolorectal resections: a plea for a randomized trial. J Laparoendosc Surg 1994;4 (4) 241- 245
PubMed
Schlachta  CMMamazza  JPoulin  EC Laparoscopicsigmoid resection for acute and chronic diverticulitis: an outcomescomparison with laparoscopic resection for nondiverticulardisease. Surg Endosc 1999;13 (7) 649- 653
PubMed
Alves  APanis  YSlim  KHeyd  BKwiatkowski  FMantion  GAssociation Français deChirurgie, French multicentre prospectiveobservational study of laparoscopic versus open colectomy for sigmoid diverticular disease. Br J Surg 2005;92 (12) 1520- 1525
PubMed
Dwivedi  AChahin  FAgrawal  S  et al.  Laparoscopic colectomy vs. opencolectomy for sigmoid diverticular disease. Dis Colon Rectum 2002;45 (10) 1309- 1314, discussion 1314-1315
PubMed
Kasparek  MSMüller  MHGlatzle  J  et al.  Postoperative colonic motilityin patients following laparoscopic-assisted and open sigmoid colectomy. J Gastrointest Surg 2003;7 (8) 1073- 1081, discussion 1081
PubMed
Regenet  NPessaux  PTuech  JJ  et al.  Prospective evaluation of the quality oflaparoscopic sigmoid resection for diverticular disease. Hepatogastroenterology 2005;52 (65) 1427- 1431
PubMed
Seitz  GSeitz  EMKasparek  MSKönigsrainer  AKreis  ME Long-termquality-of-life after open and laparoscopic sigmoid colectomy. Surg Laparosc Endosc PercutanTech 2008;18 (2) 162- 167
PubMed
Schlachta  CMMamazza  JGregoire  RBurpee  SEPoulin  EC Could laparoscopic colon and rectalsurgery become the standard of care? A review and experience with 750 procedures. Can J Surg 2003;46 (6) 432- 440
PubMed
Kennedy  GDHeise  CRajamanickam  VHarms  BFoley  EF Laparoscopy decreases postoperative complication ratesafter abdominal colectomy: results from the National Surgical QualityImprovement Program. Ann Surg 2009;249 (4) 596- 601
PubMed
Guillou  PJQuirke  PThorpe  H  et al. MRC CLASICC Trial Group, Short-term endpoints of conventional versuslaparoscopic-assisted surgery in patients with colorectal cancer (MRCCLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365 (9472) 1718- 1726
PubMed
Hazebroek  EJColor StudyGroup, COLOR: a randomized clinical trialcomparing laparoscopic and open resection for colon cancer. Surg Endosc 2002;16 (6) 949- 953
PubMed
World HealthOrganization InternationalClassification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland: World Health Organization; 1977
de Groot  VBeckerman  HLankhorst  GJBouter  LM How tomeasure comorbidity: a critical review of available methods. J Clin Epidemiol 2003;56 (3) 221- 229
PubMed
Hall  WHRamachandran  RNarayan  SJani  ABVijayakumar  S An electronic application for rapidlycalculating Charlson comorbidity score. BMCCancer2004494
PubMed:10.1186/1471-2407-4-94
Damrauer  SMBordeianou  LBerger  D Containedanastomotic leaks after colorectal surgery: are we too slow to act? Arch Surg 2009;144 (4) 333- 338
PubMed
Weeks  JCNelson  HGelber  SSargent  DSchroeder  GClinical Outcomes of Surgical Therapy (COST)Study Group, Short-term quality-of-lifeoutcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: a randomized trial. JAMA 2002;287 (3) 321- 328
PubMed
Tong  DKLaw  WL Laparoscopic versus open righthemicolectomy for carcinoma of the colon. JSLS 2007;11 (1) 76- 80
PubMed
Steele  SRBrown  TARush  RMMartin  MJ Laparoscopic vs open colectomy forcolon cancer: results from a large nationwide population-based analysis. J Gastrointest Surg 2008;12 (3) 583- 591
PubMed
Clinical Outcomes ofSurgical Therapy Study Group, A comparison oflaparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350 (20) 2050- 2059
PubMed
Veldkamp  RKuhry  EHop  WC  et al. COlon cancer Laparoscopic or Open Resection StudyGroup (COLOR), Laparoscopic surgery versusopen surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005;6 (7) 477- 484
PubMed
Hinojosa  MWMurrell  ZAKonyalian  VRMills  SNguyen  NTStamos  MJ Comparison oflaparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers. JGastrointest Surg 2007;11 (11) 1423- 1430
PubMed
Faynsod  MStamos  MJArnell  TBorden  CUdani  SVargas  H A case-control study of laparoscopic versus opensigmoid colectomy for diverticulitis. AmSurg 2000;66 (9) 841- 843
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Comparison of Patients Undergoing Laparoscopic vs Open Sigmoid Colectomy by Preoperative Factors
Table Graphic Jump LocationTable 2. Comparison of Postoperative Complications: Univariate Analysis

References

Kang  JYHoare  JTinto  Aet al   Diverticular disease of the colon—on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000. Aliment PharmacolTher 2003;17 (9) 1189- 1195
PubMed
Ambrosetti  PJenny  ABecker  CTerrier  TFMorel  P Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000;43 (10) 1363- 1367
PubMed
Rafferty  JShellito  PHyman  NHBuie  WDStandards Committee of American Society ofColon and Rectal Surgeons, Practice parametersfor sigmoid diverticulitis. Dis ColonRectum 2006;49 (7) 939- 944
PubMed
Janes  SEMeagher  AFrizelle  FA Managementof diverticulitis. BMJ 2006;332 (7536) 271- 275
PubMed
Bordeianou  LHodin  R Controversiesin the surgical management of sigmoid diverticulitis. J Gastrointest Surg 2007;11 (4) 542- 548
PubMed
Jacobs  MVerdeja  JCGoldstein  HS Minimallyinvasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1 (3) 144- 150
PubMed
Köckerling  FSchneider  CReymond  MA  et al. Laparoscopic Colorectal Surgery Study Group, Laparoscopic resection of sigmoid diverticulitis:results of a multicenter study. SurgEndosc 1999;13 (6) 567- 571
PubMed
Berthou  JCCharbonneau  P Electivelaparoscopic management of sigmoid diverticulitis. Results in aseries of 110 patients. Surg Endosc 1999;13 (5) 457- 460
PubMed
Perniceni  TBurdy  GGayet  BDubois  FBoudet  MJLevard  H [Results of elective segmental colectomy done withlaparoscopy for complicated diverticulosis]. Gastroenterol Clin Biol 2000;24 (2) 189- 192
PubMed
Smadja  CSbai Idrissi  MTahrat  M  et al.  Elective laparoscopic sigmoid colectomy fordiverticulitis: results of a prospective study. Surg Endosc 1999;13 (7) 645- 648
PubMed
Siriser  F Laparoscopic-assisted colectomy fordiverticular sigmoiditis. A single-surgeon prospective study of 65patients. Surg Endosc 1999;13 (8) 811- 813
PubMed
Slim  KPezet  DStencl  J  Jr  et al.  Prospective analysis of 40 initial laparoscopiccolorectal resections: a plea for a randomized trial. J Laparoendosc Surg 1994;4 (4) 241- 245
PubMed
Schlachta  CMMamazza  JPoulin  EC Laparoscopicsigmoid resection for acute and chronic diverticulitis: an outcomescomparison with laparoscopic resection for nondiverticulardisease. Surg Endosc 1999;13 (7) 649- 653
PubMed
Alves  APanis  YSlim  KHeyd  BKwiatkowski  FMantion  GAssociation Français deChirurgie, French multicentre prospectiveobservational study of laparoscopic versus open colectomy for sigmoid diverticular disease. Br J Surg 2005;92 (12) 1520- 1525
PubMed
Dwivedi  AChahin  FAgrawal  S  et al.  Laparoscopic colectomy vs. opencolectomy for sigmoid diverticular disease. Dis Colon Rectum 2002;45 (10) 1309- 1314, discussion 1314-1315
PubMed
Kasparek  MSMüller  MHGlatzle  J  et al.  Postoperative colonic motilityin patients following laparoscopic-assisted and open sigmoid colectomy. J Gastrointest Surg 2003;7 (8) 1073- 1081, discussion 1081
PubMed
Regenet  NPessaux  PTuech  JJ  et al.  Prospective evaluation of the quality oflaparoscopic sigmoid resection for diverticular disease. Hepatogastroenterology 2005;52 (65) 1427- 1431
PubMed
Seitz  GSeitz  EMKasparek  MSKönigsrainer  AKreis  ME Long-termquality-of-life after open and laparoscopic sigmoid colectomy. Surg Laparosc Endosc PercutanTech 2008;18 (2) 162- 167
PubMed
Schlachta  CMMamazza  JGregoire  RBurpee  SEPoulin  EC Could laparoscopic colon and rectalsurgery become the standard of care? A review and experience with 750 procedures. Can J Surg 2003;46 (6) 432- 440
PubMed
Kennedy  GDHeise  CRajamanickam  VHarms  BFoley  EF Laparoscopy decreases postoperative complication ratesafter abdominal colectomy: results from the National Surgical QualityImprovement Program. Ann Surg 2009;249 (4) 596- 601
PubMed
Guillou  PJQuirke  PThorpe  H  et al. MRC CLASICC Trial Group, Short-term endpoints of conventional versuslaparoscopic-assisted surgery in patients with colorectal cancer (MRCCLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365 (9472) 1718- 1726
PubMed
Hazebroek  EJColor StudyGroup, COLOR: a randomized clinical trialcomparing laparoscopic and open resection for colon cancer. Surg Endosc 2002;16 (6) 949- 953
PubMed
World HealthOrganization InternationalClassification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland: World Health Organization; 1977
de Groot  VBeckerman  HLankhorst  GJBouter  LM How tomeasure comorbidity: a critical review of available methods. J Clin Epidemiol 2003;56 (3) 221- 229
PubMed
Hall  WHRamachandran  RNarayan  SJani  ABVijayakumar  S An electronic application for rapidlycalculating Charlson comorbidity score. BMCCancer2004494
PubMed:10.1186/1471-2407-4-94
Damrauer  SMBordeianou  LBerger  D Containedanastomotic leaks after colorectal surgery: are we too slow to act? Arch Surg 2009;144 (4) 333- 338
PubMed
Weeks  JCNelson  HGelber  SSargent  DSchroeder  GClinical Outcomes of Surgical Therapy (COST)Study Group, Short-term quality-of-lifeoutcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: a randomized trial. JAMA 2002;287 (3) 321- 328
PubMed
Tong  DKLaw  WL Laparoscopic versus open righthemicolectomy for carcinoma of the colon. JSLS 2007;11 (1) 76- 80
PubMed
Steele  SRBrown  TARush  RMMartin  MJ Laparoscopic vs open colectomy forcolon cancer: results from a large nationwide population-based analysis. J Gastrointest Surg 2008;12 (3) 583- 591
PubMed
Clinical Outcomes ofSurgical Therapy Study Group, A comparison oflaparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350 (20) 2050- 2059
PubMed
Veldkamp  RKuhry  EHop  WC  et al. COlon cancer Laparoscopic or Open Resection StudyGroup (COLOR), Laparoscopic surgery versusopen surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005;6 (7) 477- 484
PubMed
Hinojosa  MWMurrell  ZAKonyalian  VRMills  SNguyen  NTStamos  MJ Comparison oflaparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers. JGastrointest Surg 2007;11 (11) 1423- 1430
PubMed
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