The role of laparoscopy in emergency colorectal surgery

Objectives: To assess the outcomes of the laparoscopic approach compared to those of the open approach in emergency colorectal surgery. Methods: This retrospective cohort study included all patients aged >15 years who underwent emergency colorectal surgery from 2016-2021 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patients were divided based on the surgical approach into laparoscopic and open groups. Results: A total of 241 patients (182 open resections, 59 laparoscopic approaches) were included in this study. The length of stay in the intensive care unit was shorter in the laparoscopic than in the open group (1±3 days vs. 7±16 days). After multivariable logistic regression, patients undergoing laparoscopic resection had a 70% lower risk of surgical site infection than those undergoing open surgery (adjusted odds ratio=0.33, 95% confidence interval: [0.06-1.67]), a difference that was not significant (p=0.18). Lastly, patients who underwent open surgery had a high proportion of 30-day mortality (n=26; 14.3%), compared to those who underwent laparoscopic resection (n=2; 3.4%, p=0.023). Conclusion: Laparoscopy in emergency colorectal surgery is safe and feasible, with a trend toward better outcomes. Colorectal surgery specialization is an independent predictor of an increased likelihood of undergoing laparoscopy in emergency colorectal surgery.

laparoscopy in emergency surgery ... Alselaim et al Saudi Med J 2022; Vol.43 (12) https://smj.org.saC olorectal cancer (CRC) is the third most commonly diagnosed malignancy worldwide, with a rising incidence.In 2020, more than 1.9 million new cases of CRC were diagnosed. 1A recent study demonstrated that 33% of patients with CRC required emergent surgical intervention. 2][5][6] Introduction of the laparoscopic approach has revolutionized the field of minimally invasive surgery, and it has been widely adopted in many specialties.However, despite its widespread use in elective surgery, it is unclear whether this technique can be used in emergency colorectal settings. 7,8][11][12][13][14] However, few studies have addressed the safety and feasibility of laparoscopic colorectal surgery in emergency settings; therefore, this study aimed to assess the outcomes of laparoscopic colon surgery in terms of mortality and morbidity compared with those of open surgery in emergency settings.
Methods.This retrospective cohort study included 241 patients who underwent emergency laparoscopic and open colorectal surgery from July 2016 to July 2021 at King Abdulaziz Medical City, Riyadh, Saudi Arabia.Patients who were less than 15 years old, underwent other major surgical procedures at the same time, or underwent elective colorectal surgery were excluded.
A chart review technique was used, using the BestCare system, to collect patient characteristics (age, gender, body mass index [BMI], urgency, surgeon specialty, diagnosis, American Society of Anesthesiologists [ASA] classification, white blood cell count [WBC], preop-sepsis, smoking, anticoagulation, steroid, and comorbidities), hospital characteristics (amount of blood loss, stoma, and type of resection), and postoperative outcomes (LOS, 30-day mortality [30D], intensive care unit-LOS [ICU-LOS], surgical site infection [SSI], readmission, reoperation, and complications) among patients who underwent laparoscopic surgery.The data were entered and coded in Microsoft Excel and then imported to Statistical Package for the Social Sciences, version 25.0 (IBM Corp., Armonk, NY, USA) software.This study was carried out according to the guidelines of the Declaration of Helsinki.It was approved by the Institutional Review Board (ethics approval number: RSS21R/020/07).
Statistical analysis.Statistical analyses were carried out using Statistical Package for the Social Sciences, version 25.0 (IBM Corp., Armonk, NY, USA).Categorical variables are presented as proportions and continuous variables as mean ± standard deviation (SD).Pearson χ 2 test was used for categorical variables and independent t-test was used for continuous variables to investigate the differences between subjects who underwent laparoscopic and open surgery in terms of patient and hospital characteristics.Binary logistic regression (univariate and multivariate) was used to estimate the odds ratio (OR) of undergoing laparoscopic resection to adjust for patient characteristics (age, gender, BMI, urgency, surgeon specialty, diagnosis, ASA class, WBC, preop-sepsis, smoker, anticoagulation, steroid, and comorbidities) and hospital characteristics (amount of blood loss, stoma, and type of resection).Linear and binary logistic regressions were carried out to estimate the postoperative outcomes (LOS, 30D mortality, ICU-LOS, SSI, readmission, reoperation, and complications) among patients who underwent laparoscopic surgery, with adjustments for the patient and hospital characteristics.A p-value of <0.05 and 95% confidence intervals (CI) were used to report the statistical significance and precision of results.Values are presented as a number and precentage (%).ASA: American Society of Anesthesiologists, WBC: white blood cell, BL: Burkitt's lymphoma, SD: standard deviation

Results. The baseline characteristic distributions presented in
In terms of perioperative outcomes, there was a significant difference between the 2 groups of 63 patients who presented with a preoperative sepsis outcome in the open resection (31.9%) and laparoscopic resection (9.4%) groups.Regarding the type of procedure, stoma formation was more common in patients who underwent laparoscopy (41%), while the left hemicolectomy procedure was more common in patients who underwent open surgery (30%; p=0.010).Pulmonary comorbidities were more common in the open surgery group (p=0.045),while cardiac comorbidities were more common in the laparoscopic surgery group (p=0.028).
Mean blood loss was significantly different between the 2 groups (p=0.003).However, there was no significant difference in the mean WBC between the 2 groups (p=0.439;Table 1).
As shown in Table 2, multivariable logistic regression was carried out to adjust for the correlation between patient and hospital characteristics.After adjustment, patients in the age group of 18-49 years had a 24% (95% CI: [0.02-2.43])decrease in the odds of having laparoscopic resection, which was not statistically significant (p=0.22).Furthermore, obese people had a 52% (95% CI: [0.05-5.15])lower chance of undergoing laparoscopic surgery than overweight people, and the result was not significant (p=0.58).Patients who underwent laparoscopic resection were 4.7 (95% CI: [1.10-19.7])times more likely to have anticoagulation therapy, and the result was statistically significant (p=0.03).Patients with pulmonary and cardiac comorbidities had a higher chance of undergoing laparoscopic resections than patients with other comorbidities, such as endocrine (20%), hepatic (80%), and renal diseases (60%).The results were not statistically significant.On the other hand, patients operated on by colorectal surgeons had an 83% (95% CI: [0.04-0.71])increased chance of undergoing a laparoscopic resection compared to patients operated on by non-colorectal surgeons.This result was statistically significant (p=0.01;Table 2).
Discussion.This study aimed to assess the outcomes of laparoscopic colorectal surgery in terms of mortality and morbidity compared with those of open surgery in emergency settings.Values are presented as an odd ratio and 95% confidence interval (CI).ASA: American Society of Anesthesiologists, WBC: white blood cell, BL: Burkitt's lymphoma Emergency colorectal surgery comprises a heterogeneous set of patients with different diagnoses and physical statuses.Traditional practice has always advocated for an open approach, especially in ill patients, to avoid longer operative time and pneumoperitoneum during laparoscopy, both of which might affect the hemodynamics of the patients and subsequently their postoperative outcomes. 15fter multivariate regression analysis, we found no differences in the postoperative outcomes between the laparoscopic and open approaches.Several studies have attempted to address the role of laparoscopy in emergency colorectal surgery with controversial results.Most of these studies have demonstrated that laparoscopy is equivalent to open surgery in emergency settings, with some demonstrating better outcomes with laparoscopy.A population-based study carried out in England showed that there was a statistical difference in the median LOS and lower 90-day mortality.However, patient characteristics were not fully adjusted for all differences. 16Another population-based study carried out in the United States found a statistically significant reduction in LOS, mortality rate, and all complication rates in the laparoscopic group. 17Moreover, a recent multicenter feasibility randomized clinical trial was carried out with 64 patients who showed an acceptable safety profile for laparoscopy in emergency colorectal surgery. 18ne of the several advantages of laparoscopy in elective colorectal surgery is less blood loss than in the Values are presented as a number and percentage (%).GI: gastrointestinal, GU: genitourinary, SD: standard deviation open approach. 19Our results demonstrated that, in emergency settings, the laparoscopic approach had a statistically significant lower mean blood loss than open colorectal surgery (p=0.003).
One of the controversial factors in using the laparoscopic approach in emergency settings is the physical status of the patient, which is measured using the ASA score.According to a recent study, patients with poor ASA scores had a lower chance of undergoing laparoscopy. 16However, another study found that laparoscopy was safe in selected patients with ASA scores of <3 (patients with a score of 4 were not studied). 20This study builds on the previous one by adding on the safety of this approach to all ASA scores, as the laparoscopic approach was used in 39 patients (66.1% in laparoscopic group); an ASA score of ≥3 was found to be safe in terms of amount of blood loss, 30D mortality, complications, LOS, ICU-LOS, superficial skin infection, and reoperation.
Although not statistically significant, almost half of our patients presenting to the emergency department were diagnosed with malignancies, with 99 patients who underwent the open approach and 39 who underwent laparoscopic surgery.Most of our patients were in the age group of 50-64 years, with 30.2% undergoing open resection and 42.5% undergoing laparoscopic resection.Moreover, among patients aged ≥65 years, 76 (41.7%) underwent the open approach and 23 (38.9%) the laparoscopic approach.This is consistent with the findings of a recent study showing that the emergency presentation of CRC is more common in elderly patients. 21imilar to a large study by Keller et al, 17 colorectal surgeons were the only significant variable that predicted the increased likelihood of a patient undergoing the laparoscopic approach in emergency settings.Patients operated on by colorectal surgeons had an 83% increased chance of undergoing a laparoscopic approach compared to patients operated on by noncolorectal surgeons.Another propensity score-matched study showed that 88.9% of emergency laparoscopic colorectal colectomies were carried out by colorectal surgeons. 22This observation aligns with several studies showing that colorectal surgery specialization is an independent factor for better outcomes in patients undergoing colorectal surgery. 23his study showed that the laparoscopic approach in emergency settings is safe and feasible, with a trend towards better postoperative outcomes in line with growing evidence in the literature regarding the role of laparoscopy in emergency colorectal surgery.
Study limitations.Its retrospective nature, may have impacted our results.In addition, the sample size might hinder the detection of significant associations when the adjustment of variables is attempted.Therefore, to demonstrate the role of laparoscopy in emergency colorectal surgery, future studies with larger randomized clinical trials are needed.
In conclusion, the use of laparoscopy in emergency colorectal surgery is safe and feasible, with a trend toward better outcomes.Colorectal surgery specialization is an independent predictor of an increased likelihood of undergoing laparoscopy in emergency colorectal surgery.

Table 1
Authors have no conflict of interests, and the work was not supported or funded by any drug company. Disclosure.

Table 2 -
Adjusted odds ratio of undergoing laparoscopic approach in emergency settings.

Table 2 -
Adjusted odds ratio of undergoing laparoscopic approach in emergency settings.(Continuation)

Table 3 -
Distribution of mortality and morbidity by type of intervention.

Table 4 -
Adjusted outcomes of laparoscopic versus open resection.Values are presented as odds ratio and 95% confidence interval (CI).GI: gastrointestinal, GU: genitourinary