0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Reduced Risk of Medical Morbidity and Mortality in Patients Selected for Laparoscopic Colorectal Resection in England:  A Population-Based Study FREE

Ravikrishna Mamidanna, MBBS, MRCS; Elaine M. Burns, BSc(Hons), MBCHB, MRCS; Alex Bottle, PhD; Paul Aylin, MBChB, FFPH; Christopher Stonell, MBBCh, FRCA; George B. Hanna, MBBCh, FRCS, PhD; Omar Faiz, BSc(Hons), MBBS, FRCS, MS
[+] Author Affiliations

Author Affiliations: Departments of Surgery and Cancer (Messrs Mamidanna and Faiz, Ms Burns, and Prof Hanna) and Anaesthesia (Dr Stonell), and Dr Foster Unit, Department of Primary Care and Social Medicine (Drs Bottle and Aylin), Imperial College, St Mary's Hospital, London, England.


Arch Surg. 2012;147(3):219-227. doi:10.1001/archsurg.2011.311.
Text Size: A A A
Published online

Objectives To quantify the occurrence of significant medical complications following elective colorectal resection and investigate potential differences in medical morbidity following open and minimal access colorectal surgery.

Design Retrospective analysis of Hospital Episode Statistics, which is a prospectively maintained national database.

Setting All patients undergoing colorectal resection in National Health Service trusts in England.

Patients Adult patients undergoing elective or planned surgery between April 2001 and March 2008.

Intervention Colorectal resection for benign and malignant diagnoses.

Main Outcome Measures Mortality and morbidity at 30 days and 1 year following elective colorectal resection.

Results One hundred thirty-eight thousand seven hundred thirty-five elective colorectal resections were identified between the study dates. Thirty-day in-hospital mortality was 3.4% and 1.7% following conventional and laparoscopic surgery, respectively (P < .001). Overall, the 30-day postoperative medical morbidity rate was 14.6%. Use of the minimal access approach demonstrated a significant reduction in total morbidity risk at 30 days (odds ratio, 0.79; P < .001) and 365 days (odds ratio, 0.81; P < .001) following case-mix adjustment. Multiple regression analyses demonstrated that cardiorespiratory complications and venous thromboembolism occurred less frequently during the index admission and up to 1 year following minimal access surgery when compared with the conventional approach (P < .049).

Conclusions In this population-based study, patients selected for laparoscopic colorectal resection were associated with lower risk of mortality as well as reduced cardiorespiratory and venous thromboembolic risk than those undergoing open surgery.

Elective colorectal resection is associated with low mortality but significant postoperative morbidity. Studies have described combined surgical and medical morbidity rates of 35% to 40%.1,2 Significant changes in the perioperative management such as minimal access surgery, short-acting anesthetics, regional anesthesia, and optimized postoperative pain relief with continuous epidural analgesia have been shown to accelerate postoperative recovery and reduce postoperative morbidity.3,4

The use of laparoscopic surgery for colorectal resection represents a significant and recent change in clinical practice. Randomized controlled trials have demonstrated the feasibility and safety of laparoscopic surgery in adult patients undergoing elective colorectal resection.5,6 Specifically, the UK Medical Research Council Conventional vs Laparoscopic-Assisted Surgery in Colorectal Cancer trial has shown that laparoscopic surgery for colon cancer is as effective as open surgery in terms of oncological outcome and preservation of quality of life.7 In addition, the latter and other studies support the feasibility of laparoscopic rectal surgery in this context.7,8

Minimal access surgery may offer certain advantages such as faster recovery, decreased pain, and quicker return to normal activity when compared with colorectal procedures undertaken by the conventional open approach.9 A population-based study using data from the American College of Surgeons National Surgical Quality Improvement Program has suggested that significant reduction in short-term morbidity occurs with use of laparoscopy for colectomy.10 Faiz et al11 retrospectively analyzed routinely collected data of all English National Health Service patients undergoing elective colorectal resection. They showed that patients undergoing laparoscopic surgery were at lower risk of perioperative mortality when compared with those undergoing open procedures. The same study demonstrated that the lower mortality risk of laparoscopic surgery was evident even at 1 year following operative intervention. The latter investigation did not, however, describe the causes of patient death or incidence of postoperative complications. As such, no explanation for the observed reduction in mortality among patients treated using laparoscopy was offered.

The numerous aforementioned studies have ratified the safety and demonstrated a potential perioperative benefit for laparoscopic colorectal surgery. We hypothesized that the reduced operative trauma associated with the laparoscopic approach may contribute toward the favorable short-term outcome described in various studies. It should, however, follow that this benefit should be directly accompanied by a reduction in cardiovascular, respiratory, thromboembolic, renal, and other morbidity outcomes. This study aimed to quantify from a national routinely collected English data set the incidence of major medical morbidity following elective colorectal resection. Moreover, it aimed to evaluate potential differences in medical morbidity rates arising in the short- and intermediate-term between patients operated on using laparoscopic and conventional approaches.

Data were obtained from the Hospital Episode Statistics database. Patients undergoing elective colorectal resections between April 2001 and March 2008 were included. Patients were tracked for a period of 365 days following surgery for subsequent unplanned admissions with specific problems related to cardiac, respiratory, and renal systems along with venous thromboembolism (VTE) and stroke. Preoperative comorbidity status was ascertained by recording admissions with medical concerns for a 5-year period prior to the index operation. Diagnosis codes from the International Classification of Diseases, 10th Revision (ICD-10) were used to group the complications.12

HOSPITAL EPISODE STATISTICS

The Hospital Episode Statistics database comprises administrative data from all English NHS trusts. This database has been previously described in detail in various studies.1315 A single episode is made up of diagnoses fields categorized according to the ICD-10 codes and procedure fields coded using the Office of Population Censuses and Surveys Classification of Interventions and Procedures, Version 4.4.16

DATABASE INCLUSIONS AND VARIABLE CODING

Index cases were identified using the following Office of Population Censuses and Surveys Classification of Interventions and Procedures, Version 4.4 codes for major colorectal resections:

  1. Subtotal/total resection: panproctocolectomy or total colectomy (H04, H05) and subtotal colectomy (H29).

  2. Right-sided resections: right hemicolectomy (H07), extended right hemicolectomy (H06), and transverse colectomy (H08).

  3. Left-sided resections: left hemicolectomy (H09) and sigmoid colectomy (H10).

  4. Rectal resections: anterior resection (H332-H334, H336, H338-H339), abdominoperineal resection (H331), and Hartmann resection (H335) (Hartmann resection for elective surgery was predominantly for rectal pathology).

If a patient had more than 1 resection during the study period, the first resection was taken as the index resection. The indications for surgery were categorized as malignancy (C18-C21), diverticulosis (K57), inflammatory bowel disease (Crohn, K50; ulcerative colitis, K51), and other diagnoses. Age was subcategorized into younger than 55 years, 55 to 69 years, 70 to 79 years, and older than 79 years. Nonelective or unplanned admissions and patients younger than 18 years were excluded from analyses. The Office of Population Censuses and Surveys codes used to identify laparoscopic cases were Y058 and Y752. Y714 is the code for failed minimal access, which has been in use since 2006. Patients undergoing procedures using the latter code were included in the laparoscopic group.

OUTCOME VARIABLES

Postoperative medical morbidity was classified according to the presence of relevant ICD-10 codes (eTable). In analyzing complications according to an organ system, presence of any 1 complication pertaining to that system was considered. The presence of any of the earlier-mentioned diagnosis codes (acute and chronic) in admissions up to 5 years preceding the resection was termed as preoperative comorbidity. The presence of any of the acute codes postoperatively was termed as a morbidity or medical complication. For subsequent admissions, only the primary diagnosis code was used to identify medical morbidity. Thirty-day in-hospital mortality and 365-day in-and-out-of-hospital mortality were considered in our analysis. Three-hundred-sixty-five–day mortality was only available and analyzed for patients discharged before March 31, 2006. Length of stay was taken as the duration (in days) spent in the hospital during the primary admission. Median lengths of stay (± the interquartile range [IQR]) are described. Reintervention was defined as any return to the operating theater on the index admission or on a subsequent admission within 28 days of the initial resection. This was either for laparotomy, intra-abdominal abscess drainage (image-guided or open approach), stoma, or wound complications requiring reoperation.

STATISTICAL METHODS

Statistical analyses were carried out using SPSS version 18.0 (IBM SPSS). Categorical variables were investigated using the χ2 test. For tests of significance, P values <.05 were considered significant. Medians and IQRs have been presented for nonnormal variables. Multiple regression analyses were carried out to identify predictors of postoperative medical morbidity with these covariates: age, sex, diagnosis, type of resection, surgical approach (ie, laparoscopic or open surgery), preoperative comorbidity, and reintervention or return to the operating theater within 28 days. Subgroup analyses were performed using the χ2 test and Mann-Whitney U test for categorical and continuous variables, respectively.

A total of 212 248 colonic and rectal resections were carried out between April 1, 2001, and March 31, 2008; 138 735 (65.4%) resections were elective or planned and 73 513 (34.6%) were nonelective. Of the elective resections, 92.9% (128 840) were open procedures and 7.1% (9895) were laparoscopic. In the analysis, laparoscopic surgery converted to open surgery was included in the laparoscopic group. The percentage of laparoscopic procedures performed each year increased significantly between 2001-2002 (0.8%) and 2007-2008 (19.6%). The frequencies of colorectal resections performed are described in Table 1. Detailed analyses were performed only for elective resections.

Table Graphic Jump LocationTable 1. Frequency of Colorectal Resections Carried Out in English National Health Service Trusts Between April 2001 and March 2008
DEMOGRAPHY

The characteristics of patients undergoing elective colorectal resection between the study dates are described in Table 2. The median patient age was 69 years (IQR, 59-77 years) and there were slightly more men (52.9%; n = 73 379) within the study population. Overall, 70.1% (n = 97 303) of resections were assigned a diagnostic code for colorectal malignancy and just over half of all resections were colonic procedures (53.1%; n = 73 724). Preoperative comorbidity was summarized according to organ system. The most frequently occurring comorbidities were those assigned cardiac, respiratory, and diabetic codes (Table 2).

Table Graphic Jump LocationTable 2. Descriptive Characteristics of Patients Undergoing Elective Colorectal Resection in English National Health Service Trusts Between April 1, 2001, and March 31, 2008
MORTALITY

Overall, 30-day in-hospital mortality was 3.3% (n = 4515 of 138 735). Thirty-day mortality following open colorectal surgery was 3.4% (n = 4351) and 1.7% (n = 164) after a laparoscopic procedure (P < .001). Overall, mortality within 365 days of the index procedure was 11.9% (n = 8958 of 75 101). Mortality at 1 year was higher among patients undergoing conventional surgery (12.1%; n = 8875 of 73 540) vs laparoscopic surgery (5.3%; n = 83 of 1561) (P < .001). Multiple logistic regression models for 30-day and 365-day mortality were developed with case-mix adjustment for surgical approach, age, sex, diagnosis, type of resection, and reintervention (Table 3). Laparoscopic surgery was identified as strongly associated with reduced mortality when compared with traditional surgery and corrected for other covariates (odds ratio [OR] 0.46; 95% confidence interval [CI], 0.39-0.53; P < .001 for 30-day mortality and OR, 0.43; 95% CI, 0.34-0.54; P < .001 for 365-day mortality). Other statistically significant determinants of mortality were advanced patient age (P < .001) and male sex (P < .001). The risk of death within 30 days of surgery was doubled in the presence of preoperative renal failure (P < .001) and previous stroke (P < .001).

Table Graphic Jump LocationTable 3. Multiple Logistic Regression Analysis for 30-Day and 365-Day Mortality
LENGTH OF STAY

Overall, the median length of stay for patients treated with conventional surgery was 12 days (IQR, 9-17 days) and for those who underwent laparoscopy, 7 days (IQR, 5-11 days). The median length of stay for patients who had no medical complication during their index admission was 11 days (IQR, 8-15 days) while that for patients with at least 1 medical complication postoperatively was 15 days (IQR, 11-25 days).

POSTOPERATIVE MEDICAL MORBIDITY

The presence of any single (or multiple) postoperative complication(s) was classified as medical “morbidity.” Frequencies of specific medical complications following elective colorectal resection are shown in Table 4. The overall 30-day morbidity rate was 14.6%. Morbidity occurred within 30 days in 14.8% of open cases and 12.4% of laparoscopic cases (P < .001). Medical morbidity occurring within 365 days of surgery was also lower among patients treated using the laparoscopic approach (15.8% for the open group and 13.6% for the laparoscopic group; P < .001). Medical complications were classified per organ system involvement as cardiac, respiratory, VTE (deep vein thrombosis [DVT] and pulmonary embolism), renal failure, and cerebrovascular (ischemic stroke).

Table Graphic Jump LocationTable 4. Postoperative Medical Morbidity Occurring Within 30 Days and 365 Days of Elective Colorectal Resection

Unadjusted analyses revealed that cardiac, respiratory, VTE, stroke, and renal complications arose less frequently in patients undergoing laparoscopic procedures (Table 4). Specific medical complications such as myocardial infarction, congestive cardiac failure, respiratory failure, pneumonia, DVT, and pulmonary embolism were coded more frequently in patients undergoing conventional surgery. The laparoscopic approach was associated with reduced postoperative morbidity following risk adjustment for age, sex, diagnosis, resection, and comorbidity (Table 5 and Table 6). Patients selected for laparoscopic surgery were at lower risk of cardiac (OR, 0.79; P < .001), respiratory (OR, 0.78; P < .001), VTE (OR, 0.55; P = .001), stroke (OR, 0.46; P = .008), and renal (OR, 0.72; P = .001) morbidity at 30 days following surgery. At 1 year, the same cohort demonstrated a lower risk of cardiac (OR, 0.68; P = .001), respiratory (OR, 0.75; P = .03), and VTE (OR, 0.41; P = .049) complications as compared with the open group. The risk of developing postoperative medical complications was higher in the presence of preoperative comorbidity (Table 7) and where postoperative reintervention occurred. Patients with previous thromboembolic complications demonstrated a significantly elevated risk of developing DVT or pulmonary embolism up to 1 year following surgery (OR, 9.79; 95% CI, 7.06-13.56; P < .001). The presence of a preoperative diagnosis of diabetes mellitus predisposed to postoperative cardiac complications (OR, 1.14) and renal failure (OR, 1.71) (P < .001).

Table Graphic Jump LocationTable 5. Multiple Regression Model for 30-Day Medical Complications in Patients Undergoing Elective Colorectal Resection
Table Graphic Jump LocationTable 6. Multiple Regression Model for 365-Day Medical Complications in Patients Undergoing Elective Colorectal Resection
Table Graphic Jump LocationTable 7. Mortality and Morbidity Occurring Within 30 and 365 Days of Elective Colorectal Resection in Patients With and Without Preoperative Comorbidity
COVARIATE INTERACTION

We tested for an interaction between surgical approach and age with patients younger than 55 years and undergoing open surgery as the reference group. This showed that patients aged 55 to 80 years and undergoing laparoscopic surgery had a lower risk of mortality (P < .001). Only elderly patients older than 80 years showed a higher risk of death when compared with those younger than 55 years (OR, 1.26; 95% CI, 1.00-1.59; P = .049). Similar analysis for comorbidity and surgical approach demonstrated that patients with preoperative comorbidity who underwent laparoscopic surgery had a 44% lower risk of mortality when compared with those in the open group but with no comorbidity (OR, 0.56; 95% CI, 0.44-0.79; P < .001).

Elective colorectal surgery is associated with significant postoperative medical and surgical morbidity.1,2,17,18 The current study has quantified from a routinely collected English national database the medical complications occurring following elective colorectal resection. This study has demonstrated that the incidence of medical morbidity is substantial in these patients not only in the immediate postoperative period but thereafter also. In recent years, laparoscopic surgery has become a viable alternative to the conventional approach to elective colorectal resection. This national observational study has demonstrated lower mortality and medical morbidity risk in patients selected for the laparoscopic approach to colorectal resection.

Cardiac events such as myocardial infarction, angina, and congestive heart failure have been found to occur in approximately 5% of patients undergoing noncardiac surgery and in about 30% of patients classified as high-risk surgical candidates.19 General anesthesia is associated with respiratory effects including reduced vital capacity, decreased respiratory rate, and inefficient breathing resulting in a decrease in lung expansion and gas exchange.20 The physiological impact of the pneumoperitoneum incurred at the time of laparoscopy includes an increase in cardiac afterload with an associated decrease in venous return.21,22 Our findings suggest, however, that such intraoperative physiological changes do not translate into increased postoperative complications. Case series and small trials are usually not adequately powered to identify differences in rarely occurring events.23

In the present investigation, patients undergoing laparoscopic surgery demonstrated a lower incidence of acute myocardial infarction, congestive cardiac failure, pneumonia, and acute respiratory failure. An explanation for these findings might be accounted for by the reduced surgical stress inflicted by laparoscopic surgery when compared with traditional care. Minimal access surgery for colorectal resection is associated with reduced postoperative pain, earlier mobilization, and earlier return of bowel function.24,25 However, these benefits are dually associated with enhanced-recovery protocols also. In the United Kingdom, many enthusiasts for laparoscopy are also proponents of enhanced recovery. In our study, an excess of patients receiving enhanced-recovery care in the laparoscopic group could potentially have contributed, to some extent, to the reduced morbidity identified in this group. Conversely, it has to be acknowledged that laparoscopy represents a major component of enhanced-recovery protocols and may mediate an accelerated recovery through an attenuated surgical stress response.2628

The current study has identified important findings regarding VTE risk and colorectal surgery. Patients selected to undergo a laparoscopic approach were at nearly half the risk of developing VTE at 30 days when compared with those undergoing open surgery. Routine inpatient data (as relate to our findings) are unlikely to identify a significant proportion of cases of DVT that are treated on an outpatient basis if occurring beyond discharge. On analysis of DVT cases on the index admission, however, a statistically significant increase in the incidence of DVT following open surgery was still identified. This may in part be explained by a higher number of patients with a history of VTE in the open group. Risk adjustment including preoperative comorbidity demonstrated a 10-fold risk in developing VTE within 30 days of surgery among patients with a history of VTE. Certainly, laparoscopy is associated with early ambulation, which may limit postoperative venous stasis. Conversely, prospective randomized studies comparing laparoscopic surgery with the open approach have reported longer operations in the laparoscopic group,29,30 potentially predisposing toward intraoperative venous stasis. As stated previously, a confounding factor such as greater use of thoracic epidural analgesia in laparoscopic surgery, which cannot be substantiated from this study but is an intervention associated with reduced thromboembolic events, might account for this finding. Last, the surgical stress response is a recognized procoagulant state. The reduced stress response following laparoscopic surgery may therefore explain the study findings. To this extent, the reduced tissue trauma associated with less intraoperative blood loss and lower transfusion requirements appear to be more important determinants of outcome.31,32

The benefits of laparoscopic surgery are not limited to the younger population. Studies have suggested that it is safe and beneficial among high-risk groups such as morbidly obese patients and those with high American Society of Anesthesiologists grades.3335 Studies have also ratified its safety in elderly cohorts.32,36 This has prompted an increase in the use of minimally invasive techniques in elderly patients. Age-related reduction in physiological reserves and presence of comorbidities make elderly patients susceptible to complications. From the covariate interaction analyses in our study, it is possible to suggest that laparoscopy is safe and possibly advantageous among elderly patients and those with associated comorbidity.

The current study analyzed routinely collected data. Such data are collected by nonclinicians, albeit trained coders, which questions the reliability. However, the accuracy of UK hospital administrative data was found to approximate 84% and 97% for diagnostic and operation codes, respectively, in a systematic review of coding accuracy.37 The strengths of these routinely collected data sets are that they capture all patients and thereby negate the potential reporting bias inherent in any carefully selected series of patients. However, this study is not immune to selection bias regarding the surgical approach, and evidence from randomized controlled trials with carefully constrained inclusion criteria is essential to draw firm conclusions. Obesity is a known predictor of postoperative morbidity following colectomy.38,39 Although some recent studies have shown laparoscopic colectomy to be feasible in obese patients with comparable outcomes with nonobese patients, many surgeons remain hesitant to offer a minimally invasive approach to this patient group.4042 Hospital Episode Statistics data do not include patient body mass index and hence cannot account for this potential difference in patient selection. Similarly, a history of abdominal surgery cannot be ascertained from administrative data sources such as Hospital Episode Statistics and may lead to unaccounted for bias between patients selected for the conventional and laparoscopic approach. Nevertheless, the large numbers of patients involved in such population-based series mean that rarely occurring events can be detected in sufficient volume to permit comparative analyses. One further limitation that we recognize is that morbidity occurring outside of the hospital, ie, managed on an outpatient basis, was not included in our data. Thus, this study underestimates total complications occurring following surgery. Severe complications are, however, likely to require readmission and therefore be included. For these reasons, as well as the exclusion of surgical morbidity, we accept that total actual postoperative morbidity is likely to be higher than our recorded figures.

Using a national database, this study has quantified the medical morbidity arising following elective colorectal resection. Patients selected for the laparoscopic approach in this large population-based observational study were at reduced risk of mortality as well as cardiorespiratory and possibly venous thromboembolic complications in the short- and intermediate-term.

Correspondence: Omar Faiz, BSc(Hons), MBBS, FRCS, MS, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, South Wharf Road, London W21NY, England (omarfaiz@aol.com).

Accepted for Publication: August 12, 2011.

Published Online: November 21, 2011. doi:10.1001/archsurg.2011.311

Author Contributions:Study concept and design: Mamidanna, Burns, Hanna, and Faiz. Acquisition of data: Burns, Bottle, and Aylin. Analysis and interpretation of data: Mamidanna, Bottle, and Stonell. Drafting of the manuscript: Mamidanna. Critical revision of the manuscript for important intellectual content: Burns, Bottle, Aylin, Stonell, Hanna, and Faiz. Statistical analysis: Bottle and Faiz. Administrative, technical, and material support: Mamidanna. Study supervision: Aylin and Faiz.

Financial Disclosure: The Dr Foster Unit at Imperial College is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust, which is funded by the National Institute for Health Research.

Funding/Support: The Dr Foster Unit is largely funded by a research grant from Dr Foster Intelligence (an independent health service research organization).

Previous Presentations: The abstract was presented at The Association of Coloproctology of Great Britain and Ireland meeting; June 22, 2011; Birmingham, England, and the Tripartite Colorectal Meeting; July 4, 2011; Cairns, Australia.

Additional Information: We have ethics approval under Section 251 (formerly Section 60) granted by the National Information Governance Board for Health and Social Care (formerly the Patient Information Advisory Group). We have approval for using these data for research from the South East Research Ethics Committee.

Additional Contributions: We are grateful for support from the National Institute for Health Research Biomedical Research Centre funding scheme.

Braga M, Vignali A, Gianotti L,  et al.  Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome.  Ann Surg. 2002;236(6):759-766, 767
PubMed   |  Link to Article
Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K.Association Française de Chirurgie.  Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study.  Arch Surg. 2005;140(3):278-283, discussion 284
PubMed   |  Link to Article
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery.  Lancet. 2003;362(9399):1921-1928
PubMed   |  Link to Article
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome.  Am J Surg. 2002;183(6):630-641
PubMed   |  Link to Article
Lacy AM, García-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(9325):2224-2229
PubMed   |  Link to Article
Hazebroek EJ.Color Study Group.  COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer.  Surg Endosc. 2002;16(6):949-953
PubMed   |  Link to Article
Jayne DG, Guillou PJ, Thorpe H,  et al; UK MRC CLASICC Trial Group.  Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group.  J Clin Oncol. 2007;25(21):3061-3068
PubMed   |  Link to Article
Liang JT, Huang KC, Lai HS, Lee PH, Jeng YM. Oncologic results of laparoscopic versus conventional open surgery for stage II or III left-sided colon cancers: a randomized controlled trial.  Ann Surg Oncol. 2007;14(1):109-117
PubMed   |  Link to Article
Champault GG, Barrat C, Raselli R, Elizalde A, Catheline JM. Laparoscopic versus open surgery for colorectal carcinoma: a prospective clinical trial involving 157 cases with a mean follow-up of 5 years.  Surg Laparosc Endosc Percutan Tech. 2002;12(2):88-95
PubMed   |  Link to Article
Kennedy GD, Heise C, Rajamanickam V, Harms B, Foley EF. Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program.  Ann Surg. 2009;249(4):596-601
PubMed   |  Link to Article
Faiz O, Warusavitarne J, Bottle A, Tekkis PP, Darzi AW, Kennedy RH. Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006.  Dis Colon Rectum. 2009;52(10):1695-1704
PubMed   |  Link to Article
World Health Organization.  International Statistical Classification of Diseases, 10th Revision (ICD-10). Geneva, Switzerland: World Health Organization; 1992
Faiz O, Warusavitarne J, Bottle A,  et al.  Nonelective excisional colorectal surgery in English National Health Service Trusts: a study of outcomes from Hospital Episode Statistics Data between 1996 and 2007.  J Am Coll Surg. 2010;210(4):390-401
PubMed   |  Link to Article
Aylin P, Bottle A, Elliott P, Jarman B. Surgical mortality: hospital episode statistics v central cardiac audit database.  BMJ. 2007;335(7625):839, author reply 839-840
PubMed   |  Link to Article
Judge A, Chard J, Learmonth I, Dieppe P. The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England.  J Public Health (Oxf). 2006;28(2):116-124
PubMed   |  Link to Article
 OPCS: Classification of Interventions and Procedures Version 4.4. Norwich, England: The Stationery Office; 2007
Tekkis PP, Kocher HM, Bentley AJ,  et al.  Operative mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery.  Dis Colon Rectum. 2000;43(11):1528-1532, 1532-1534
PubMed   |  Link to Article
Tekkis PP, Poloniecki JD, Thompson MR, Stamatakis JD. Operative mortality in colorectal cancer: prospective national study.  BMJ. 2003;327(7425):1196-1201
PubMed   |  Link to Article
Mathias JM. Setting up a beta-blocker protocol to prevent cardiac complications.  OR Manager. 2005;21(5):1, 8-10
PubMed
Daganou M, Dimopoulou I, Michalopoulos N,  et al.  Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting.  Chest. 1998;113(5):1285-1289
PubMed   |  Link to Article
Kashtan J, Green JF, Parsons EQ, Holcroft JW. Hemodynamic effect of increased abdominal pressure.  J Surg Res. 1981;30(3):249-255
PubMed   |  Link to Article
Joris JL, Noirot DP, Legrand MJ, Jacquet NJ, Lamy ML. Hemodynamic changes during laparoscopic cholecystectomy.  Anesth Analg. 1993;76(5):1067-1071
PubMed   |  Link to Article
Basse L, Raskov HH, Hjort Jakobsen D,  et al.  Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition.  Br J Surg. 2002;89(4):446-453
PubMed   |  Link to Article
Wind J, Polle SW, Fung Kon Jin PH,  et al; Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group.  Systematic review of enhanced recovery programmes in colonic surgery.  Br J Surg. 2006;93(7):800-809
PubMed   |  Link to Article
Artuso D, Wayne M, Cassaro S, Cerabona T, Teixeira J, Grossi R. Hemodynamic changes during laparoscopic gastric bypass procedures.  Arch Surg. 2005;140(3):289-292
PubMed   |  Link to Article
Miyake H, Kawabata G, Gotoh A,  et al.  Comparison of surgical stress between laparoscopy and open surgery in the field of urology by measurement of humoral mediators.  Int J Urol. 2002;9(6):329-333
PubMed   |  Link to Article
Madbouly KM, Senagore AJ, Delaney CP. Endogenous morphine levels after laparoscopic versus open colectomy.  Br J Surg. 2010;97(5):759-764
PubMed   |  Link to Article
Sáenz J, Asuero MS, Villafruela J,  et al.  Immunohumoral response during laparoscopic and open living donor nephrectomy: an experimental model.  Transplant Proc. 2007;39(7):2102-2104
PubMed   |  Link to Article
Buunen M, Veldkamp R, Hop WC,  et al; Colon Cancer Laparoscopic or Open Resection Study Group.  Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial.  Lancet Oncol. 2009;10(1):44-52
PubMed   |  Link to Article
Fleshman J, Sargent DJ, Green E,  et al; for The Clinical Outcomes of Surgical Therapy Study Group.  Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial.  Ann Surg. 2007;246(4):655-662, discussion 662-664
PubMed   |  Link to Article
Kiran RP, Delaney CP, Senagore AJ, Millward BL, Fazio VW. Operative blood loss and use of blood products after laparoscopic and conventional open colorectal operations.  Arch Surg. 2004;139(1):39-42
PubMed   |  Link to Article
Lian L, Kalady M, Geisler D, Kiran RP. Laparoscopic colectomy is safe and leads to a significantly shorter hospital stay for octogenarians.  Surg Endosc. 2010;24(8):2039-2043
PubMed   |  Link to Article
Nguyen NT, Lee SL, Goldman C,  et al.  Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial.  J Am Coll Surg. 2001;192(4):469-476, discussion 476-477
PubMed   |  Link to Article
Sugerman HJ, Kellum JM, Engle KM,  et al.  Gastric bypass for treating severe obesity.  Am J Clin Nutr. 1992;55(2):(suppl)  560S-566S
PubMed
Marks JH, Kawun UB, Hamdan W, Marks G. Redefining contraindications to laparoscopic colorectal resection for high-risk patients.  Surg Endosc. 2008;22(8):1899-1904
PubMed   |  Link to Article
Person B, Cera SM, Sands DR,  et al.  Do elderly patients benefit from laparoscopic colorectal surgery?  Surg Endosc. 2008;22(2):401-405
PubMed   |  Link to Article
Campbell SE, Campbell MK, Grimshaw JM, Walker AE. A systematic review of discharge coding accuracy.  J Public Health Med. 2001;23(3):205-211
PubMed   |  Link to Article
Pikarsky AJ, Saida Y, Yamaguchi T,  et al.  Is obesity a high-risk factor for laparoscopic colorectal surgery?  Surg Endosc. 2002;16(5):855-858
PubMed   |  Link to Article
Gendall KA, Raniga S, Kennedy R, Frizelle FA. The impact of obesity on outcome after major colorectal surgery.  Dis Colon Rectum. 2007;50(12):2223-2237
PubMed   |  Link to Article
Khoury W, Kiran RP, Jessie T, Geisler D, Remzi FH. Is the laparoscopic approach to colectomy safe for the morbidly obese?  Surg Endosc. 2010;24(6):1336-1340
PubMed   |  Link to Article
Hemandas AK, Abdelrahman T, Flashman KG,  et al.  Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.  Ann Surg. 2010;252(1):84-89
PubMed   |  Link to Article
Park JW, Lim SW, Choi HS, Jeong SY, Oh JH, Lim SB. The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians.  Surg Endosc. 2010;24(7):1679-1685
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Frequency of Colorectal Resections Carried Out in English National Health Service Trusts Between April 2001 and March 2008
Table Graphic Jump LocationTable 2. Descriptive Characteristics of Patients Undergoing Elective Colorectal Resection in English National Health Service Trusts Between April 1, 2001, and March 31, 2008
Table Graphic Jump LocationTable 3. Multiple Logistic Regression Analysis for 30-Day and 365-Day Mortality
Table Graphic Jump LocationTable 4. Postoperative Medical Morbidity Occurring Within 30 Days and 365 Days of Elective Colorectal Resection
Table Graphic Jump LocationTable 5. Multiple Regression Model for 30-Day Medical Complications in Patients Undergoing Elective Colorectal Resection
Table Graphic Jump LocationTable 6. Multiple Regression Model for 365-Day Medical Complications in Patients Undergoing Elective Colorectal Resection
Table Graphic Jump LocationTable 7. Mortality and Morbidity Occurring Within 30 and 365 Days of Elective Colorectal Resection in Patients With and Without Preoperative Comorbidity

References

Braga M, Vignali A, Gianotti L,  et al.  Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome.  Ann Surg. 2002;236(6):759-766, 767
PubMed   |  Link to Article
Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K.Association Française de Chirurgie.  Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study.  Arch Surg. 2005;140(3):278-283, discussion 284
PubMed   |  Link to Article
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery.  Lancet. 2003;362(9399):1921-1928
PubMed   |  Link to Article
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome.  Am J Surg. 2002;183(6):630-641
PubMed   |  Link to Article
Lacy AM, García-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(9325):2224-2229
PubMed   |  Link to Article
Hazebroek EJ.Color Study Group.  COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer.  Surg Endosc. 2002;16(6):949-953
PubMed   |  Link to Article
Jayne DG, Guillou PJ, Thorpe H,  et al; UK MRC CLASICC Trial Group.  Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group.  J Clin Oncol. 2007;25(21):3061-3068
PubMed   |  Link to Article
Liang JT, Huang KC, Lai HS, Lee PH, Jeng YM. Oncologic results of laparoscopic versus conventional open surgery for stage II or III left-sided colon cancers: a randomized controlled trial.  Ann Surg Oncol. 2007;14(1):109-117
PubMed   |  Link to Article
Champault GG, Barrat C, Raselli R, Elizalde A, Catheline JM. Laparoscopic versus open surgery for colorectal carcinoma: a prospective clinical trial involving 157 cases with a mean follow-up of 5 years.  Surg Laparosc Endosc Percutan Tech. 2002;12(2):88-95
PubMed   |  Link to Article
Kennedy GD, Heise C, Rajamanickam V, Harms B, Foley EF. Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program.  Ann Surg. 2009;249(4):596-601
PubMed   |  Link to Article
Faiz O, Warusavitarne J, Bottle A, Tekkis PP, Darzi AW, Kennedy RH. Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006.  Dis Colon Rectum. 2009;52(10):1695-1704
PubMed   |  Link to Article
World Health Organization.  International Statistical Classification of Diseases, 10th Revision (ICD-10). Geneva, Switzerland: World Health Organization; 1992
Faiz O, Warusavitarne J, Bottle A,  et al.  Nonelective excisional colorectal surgery in English National Health Service Trusts: a study of outcomes from Hospital Episode Statistics Data between 1996 and 2007.  J Am Coll Surg. 2010;210(4):390-401
PubMed   |  Link to Article
Aylin P, Bottle A, Elliott P, Jarman B. Surgical mortality: hospital episode statistics v central cardiac audit database.  BMJ. 2007;335(7625):839, author reply 839-840
PubMed   |  Link to Article
Judge A, Chard J, Learmonth I, Dieppe P. The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England.  J Public Health (Oxf). 2006;28(2):116-124
PubMed   |  Link to Article
 OPCS: Classification of Interventions and Procedures Version 4.4. Norwich, England: The Stationery Office; 2007
Tekkis PP, Kocher HM, Bentley AJ,  et al.  Operative mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery.  Dis Colon Rectum. 2000;43(11):1528-1532, 1532-1534
PubMed   |  Link to Article
Tekkis PP, Poloniecki JD, Thompson MR, Stamatakis JD. Operative mortality in colorectal cancer: prospective national study.  BMJ. 2003;327(7425):1196-1201
PubMed   |  Link to Article
Mathias JM. Setting up a beta-blocker protocol to prevent cardiac complications.  OR Manager. 2005;21(5):1, 8-10
PubMed
Daganou M, Dimopoulou I, Michalopoulos N,  et al.  Respiratory complications after coronary artery bypass surgery with unilateral or bilateral internal mammary artery grafting.  Chest. 1998;113(5):1285-1289
PubMed   |  Link to Article
Kashtan J, Green JF, Parsons EQ, Holcroft JW. Hemodynamic effect of increased abdominal pressure.  J Surg Res. 1981;30(3):249-255
PubMed   |  Link to Article
Joris JL, Noirot DP, Legrand MJ, Jacquet NJ, Lamy ML. Hemodynamic changes during laparoscopic cholecystectomy.  Anesth Analg. 1993;76(5):1067-1071
PubMed   |  Link to Article
Basse L, Raskov HH, Hjort Jakobsen D,  et al.  Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition.  Br J Surg. 2002;89(4):446-453
PubMed   |  Link to Article
Wind J, Polle SW, Fung Kon Jin PH,  et al; Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group.  Systematic review of enhanced recovery programmes in colonic surgery.  Br J Surg. 2006;93(7):800-809
PubMed   |  Link to Article
Artuso D, Wayne M, Cassaro S, Cerabona T, Teixeira J, Grossi R. Hemodynamic changes during laparoscopic gastric bypass procedures.  Arch Surg. 2005;140(3):289-292
PubMed   |  Link to Article
Miyake H, Kawabata G, Gotoh A,  et al.  Comparison of surgical stress between laparoscopy and open surgery in the field of urology by measurement of humoral mediators.  Int J Urol. 2002;9(6):329-333
PubMed   |  Link to Article
Madbouly KM, Senagore AJ, Delaney CP. Endogenous morphine levels after laparoscopic versus open colectomy.  Br J Surg. 2010;97(5):759-764
PubMed   |  Link to Article
Sáenz J, Asuero MS, Villafruela J,  et al.  Immunohumoral response during laparoscopic and open living donor nephrectomy: an experimental model.  Transplant Proc. 2007;39(7):2102-2104
PubMed   |  Link to Article
Buunen M, Veldkamp R, Hop WC,  et al; Colon Cancer Laparoscopic or Open Resection Study Group.  Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial.  Lancet Oncol. 2009;10(1):44-52
PubMed   |  Link to Article
Fleshman J, Sargent DJ, Green E,  et al; for The Clinical Outcomes of Surgical Therapy Study Group.  Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial.  Ann Surg. 2007;246(4):655-662, discussion 662-664
PubMed   |  Link to Article
Kiran RP, Delaney CP, Senagore AJ, Millward BL, Fazio VW. Operative blood loss and use of blood products after laparoscopic and conventional open colorectal operations.  Arch Surg. 2004;139(1):39-42
PubMed   |  Link to Article
Lian L, Kalady M, Geisler D, Kiran RP. Laparoscopic colectomy is safe and leads to a significantly shorter hospital stay for octogenarians.  Surg Endosc. 2010;24(8):2039-2043
PubMed   |  Link to Article
Nguyen NT, Lee SL, Goldman C,  et al.  Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial.  J Am Coll Surg. 2001;192(4):469-476, discussion 476-477
PubMed   |  Link to Article
Sugerman HJ, Kellum JM, Engle KM,  et al.  Gastric bypass for treating severe obesity.  Am J Clin Nutr. 1992;55(2):(suppl)  560S-566S
PubMed
Marks JH, Kawun UB, Hamdan W, Marks G. Redefining contraindications to laparoscopic colorectal resection for high-risk patients.  Surg Endosc. 2008;22(8):1899-1904
PubMed   |  Link to Article
Person B, Cera SM, Sands DR,  et al.  Do elderly patients benefit from laparoscopic colorectal surgery?  Surg Endosc. 2008;22(2):401-405
PubMed   |  Link to Article
Campbell SE, Campbell MK, Grimshaw JM, Walker AE. A systematic review of discharge coding accuracy.  J Public Health Med. 2001;23(3):205-211
PubMed   |  Link to Article
Pikarsky AJ, Saida Y, Yamaguchi T,  et al.  Is obesity a high-risk factor for laparoscopic colorectal surgery?  Surg Endosc. 2002;16(5):855-858
PubMed   |  Link to Article
Gendall KA, Raniga S, Kennedy R, Frizelle FA. The impact of obesity on outcome after major colorectal surgery.  Dis Colon Rectum. 2007;50(12):2223-2237
PubMed   |  Link to Article
Khoury W, Kiran RP, Jessie T, Geisler D, Remzi FH. Is the laparoscopic approach to colectomy safe for the morbidly obese?  Surg Endosc. 2010;24(6):1336-1340
PubMed   |  Link to Article
Hemandas AK, Abdelrahman T, Flashman KG,  et al.  Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.  Ann Surg. 2010;252(1):84-89
PubMed   |  Link to Article
Park JW, Lim SW, Choi HS, Jeong SY, Oh JH, Lim SB. The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians.  Surg Endosc. 2010;24(7):1679-1685
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Data Supplements
Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 14

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles