Redefining contraindications to laparoscopic colorectal resection for high-risk patients.
BACKGROUND
Patients with major comorbidities often are denied laparoscopic colorectal resections because they are thought to be at too "high risk." Paradoxically, these patients generally have the most to gain from a minimally invasive surgical approach. This study aimed to examine the feasibility and safety of laparoscopic colorectal resection to determine whether it is contraindicated for "high-risk" patients.


METHODS
From August 1996 to February 2004, 368 consecutive patients (95 men) undergoing a laparoscopic colorectal procedure by a single surgeon were prospectively studied with regard to pre-, peri-, and postoperative events. High-risk patients (n = 190) were defined as elderly (age, >80 years; n = 28), morbidly obese (body mass index [BMI], >30 kg/m(2); n = 55), American Society of Anesthesiology (ASA) 3 or 4 (n = 130), and recipients of preoperative radiotherapy (n = 54). Multiple risk factors were found for 67 patients, 7 of whom had three risk factors. The median age of the patients was 66 years (range, 19-92 years). The diagnoses included rectal cancer (n = 48), diverticulitis (n = 43), colon cancer (n = 34), benign polyp (n = 26), and other (n = 39). The following procedures were performed: colon resection (n = 114; left, 63; right, 41; total abdominal colectomy, 10), rectal resection (low anterior resection or pouch) (n = 49), coloanal anastomosis (n = 23), and other (n = 4). Data regarding intent to treat, operative events, morbidity, mortality, and outcomes were analyzed and form the basis of this report.


RESULTS
No mortalities occurred. The major morbidity rate was 2%. There were no anastomotic leaks. The cases were laparoscopically performed (94%) or laparoscopically assisted, or were converted to open procedure (3%). The median estimated blood loss was 200 ml, and only 5% required perioperative transfusion. The perioperative course involved the following median periods: 2 days until flatus, 3 days until bowel movement, 1 day until clear liquid diet, 3 days until a regular diet, and 5 days until hospital discharge.


CONCLUSIONS
In experienced hands, laparoscopic colorectal resection can be performed safely for "high-risk" surgical patients. The better than expected outcomes in this patient population reinforce the benefits of minimally invasive surgery for this patient group and argues against using parameters of increased age, morbid obesity, high ASA class, or preoperative radiation alone as contraindications to even complex laparoscopic colorectal procedures.
Marks
John H
JH
Section of Colorectal Surgery, The Lankenau Hospital and Institute for Medical Research, Wynnewood, PA 19096, USA. MarksJ@MLHS.org
Kawun
Ulana B
UB
Hamdan
Wajdi
W
Marks
Gerald
G
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data; D003107:Colorectal Surgery / Q000009:adverse effects / Q000379:methods*; D000075202:Contraindications; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007410:Intestinal Diseases / Q000601:surgery*; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome