Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy.
OBJECTIVE
The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection.


METHODS
The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package).


RESULTS
The series included 36 men and 24 women, with a mean age of 72 years (range, 38-87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90-360), morbidity: 31% and stay: 9 days (range, 6-43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1-2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men.


CONCLUSIONS
Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.
Targarona
Eduardo M
EM
Hospital Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain. etargarona@santpau.es
Balague
Carmen
C
Pernas
Juan Carlos
JC
Martinez
Carmen
C
Berindoague
Rene
R
Gich
Ignasi
I
Trias
Manuel
M
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010388:Pelvis / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000473:pathology; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome