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Background: Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection., Objective: The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps., Design: This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries., Setting: This study was conducted at a single institution., Patients: All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp., Main Outcome Measures: Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured., Results: Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days., Limitations: This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up., Conclusions: Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Aim: The safety and efficacy of laparoscopic surgery for colon cancer is well established but its uptake in the province has not been previously explored. We report an investigation of the trends of open and laparoscopic surgery for colon cancer in Ontario, Canada., Method: A retrospective cross-sectional time-series analysis examining population-based rates of elective surgery for colon cancer among 10.5 million adults in Ontario was conducted from 1 April 2002 to 31 March 2009. Databases were linked to assess quarterly elective procedure rates over time., Results: During the study period, 3950 laparoscopic and 13 048 open elective colon cancer operations were performed in Ontario. The overall quarterly rate of colon cancer surgery remained stable at an average of 5.8 per 100000 population (P=0.10). From the first and last quarter, the rate of laparoscopic operations increased nearly threefold from 0.8 to 2.2 per 100000 population with a notable increase after 2005 (P<0.01). In contrast, open surgery decreased by more than 30% from 5.3 to 3.5 per 100 000 population (P<0.01). If current trends continue, the projected proportion of laparoscopic colon operations is estimated to reach 41% by 2015. Patients receiving open surgery had a significantly higher preoperative comorbidity (Charlson comorbidity score≥3) than those having laparoscopy (47.8%vs 39.1%, standardized difference 0.26)., Conclusion: Trends in Ontario of laparoscopic colon cancer surgery show an increase between 2002 and 2009, but the incidence remains lower than for open surgery., (© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.)

Background: Laparoscopic surgery may become the standard of care for the treatment of colorectal disease. Little is known regarding North American patterns of practice or the limiting factors and strategies for adoption among surgeons., Methods: We sent a 28-item questionnaire to all general surgeon members of the Royal College of Physicians and Surgeons of Canada. We derived descriptive and correlative information using chi(2), Wilcoxon rank sum and Student t tests and multivariate logistic regression., Results: The return rate was 55% (694/1266). A total of 67% (462/694; 95% confidence interval 63%-70%) of respondents perform colorectal surgery. Of these, 54% perform laparoscopic colorectal surgery. Multivariate logistic regression identified 5 factors related to performing laparoscopic colorectal surgery: fewer years in practice (p < 0.001), male sex (p = 0.015), practising in the province of Quebec (p = 0.005), university-hospital affiliation (p = 0.034) and minimally invasive surgery fellowship training (p = 0.023). Lack of adequate operating time and formal training were the main reasons cited by surgeons not offering laparoscopic colon resections. Most surgeons (67%) felt that site visits from a minimally invasive surgeon would represent the most effective training method for acquiring advanced laparoscopic skills., Conclusion: About half of Canadian general surgeons offer laparoscopic colorectal resections. Recent graduation, male sex, practice location, university-hospital affiliation and minimally invasive surgery training are significant predictors for offering a laparoscopic approach. Lack of operative time and formal training are the main barriers to adoption of the technique. Site visits by trained laparoscopic surgeons is the preferred method of acquiring advanced skills.

Purpose: The purpose was to determine if the perioperative benefits associated with laparoscopic colectomies are maintained as operative time increases., Methods: A retrospective review was performed of a database that was prospectively collected from April 1991 to May 2005. Since operative time distributions were different, patients were divided into three groups: laparoscopic right colectomy or ileocecal resection, sigmoid resection, and total abdominal colectomy. The following outcomes were assessed: intraoperative and postoperative complications, days to surgical diet, length of stay, 30-day mortality, and the presence of a learning curve., Results: Following exclusions, there were 231 right colon and ileocecal resections, 210 sigmoid colectomies, and 46 total abdominal colectomies. With increasing operative time in both right/ileocecal and sigmoid resections, logistic regression demonstrated no significant association between intraoperative and postoperative complications, days to surgical diet, or length of stay. Weight was significantly correlated with increasing operative time in the right/ileocecal and sigmoid resection groups. In the total abdominal colectomy group, significant relationships between increased operative time and postoperative complications (P = 0.04), days to surgical diet (P = 0.02), and hospital stay (P = 0.03) were found. An operative time cut-point was determined in the total abdominal colectomy group. Patients with operative times >270 minutes were more likely to have postoperative complications (P = 0.024), longer ileus (five vs. three median days to surgical diet, P = 0.003), and longer length of stay (seven vs. five days, P = 0.04). This increased risk remained significant after adjusting for weight and diagnosis. No significant learning curve was identified., Conclusion: Increasing operative time does not appear to adversely affect perioperative outcomes in segmental colectomies. Total abdominal colectomies lasting more than 270 minutes were associated with increased postoperative complications, days to surgical diet, and length of stay.

Purpose: This study was designed to assess whether the exclusion criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials affected the generalizability of their findings., Methods: A prospective database of consecutive laparoscopic resections performed for colon cancer was reviewed. Patients were categorized into two groups: inclusion group and exclusion group, based on the selection criteria used in the Clinical Outcomes of Surgical Therapy and Colon Cancer Laparoscopic or Open Resection trials. Baseline and perioperative data were analyzed by using t-tests, Wilcoxon's rank-sum, chi-squared, and Fisher's exact test. Kaplan-Meier survival curves, followed by adjustment for tumor nodes metastasis stage and age utilizing a Cox proportional hazard model, were performed., Results: The inclusion group had 221 patients and the exclusion group had 166 (median age and gender distribution were similar). The exclusion group had a higher conversion rate (23 vs. 11.3 percent; P=0.0023). There was no difference in intraoperative complications (9 percent for exclusion group vs. 8.6 percent for inclusion group; P=0.8), operative time (180 minutes for exclusion group vs.172 minutes for inclusion group; P=0.24), or postoperative complication rates (33.7 percent for exclusion group vs. 26 percent for inclusion group; P=0.13). No difference was detected in perioperative mortality rates, length of stay, days to diet as tolerated, and adjusted two-year survival., Conclusions: No differences were found in outcomes between the two groups in terms of operative/postoperative complications, length of stay, perioperative mortality, and two-year survival. It seems that all patients with colon cancer can potentially benefit from a laparoscopic approach.

Purpose: Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares their perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I-III) disease., Methods: A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student's t-tests as required and P

Background: This purpose of this study was to examine whether survival is affected when laparoscopic resections for colorectal cancer are converted to open surgery., Methods: A prospective database of 377 consecutive laparoscopic resections for colorectal cancer performed between November 1991 and June 2002 was reviewed. The TNM classification for colorectal cancer and the Kaplan-Meier method were used to determine survival curves for each group., Results: Conversion to an open procedure was required in 46 cases (12.8%). Converted and laparoscopic groups were similar in age, sex, comorbidities, and location and size of tumor. The converted group had a significantly higher weight (75 kg vs 69 kg, p = 0.013) and conversion score (2.18 vs. 1.87, p = 0.005). Patients with stage IV disease were significantly more likely to be converted than those with stage I-III disease (23.0% vs 11.2%, p = 0.04). There was no difference in the conversion rate between patients with stage I (14%), II (8%), or III (13%) colorectal cancers. Median follow-up was 30.5 months for stage I-III and 10.8 months for stage IV cancers. There were 190 patients followed at least 2 years and 73 patients followed at least 5 years. Survival curves demonstrate significantly lower 2-year survival after converted procedures as compared to laparoscopic (75.7% vs 87.2%, p = 0.02), with a trend toward lower 5-year survival (61.9% vs 69.7%, p = 0.077)., Conclusions: Survival rates at 2 and 5 years are lower for patients in the converted group compared to patients with LR. This finding could have serious impact on the treatment of patients with colorectal cancer. Further confirmation is required.