title: Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure?
abstract: BACKGROUND
  Anastomotic complications such as leakage and bleeding remain among the most serious complications of laparoscopic colorectal surgery. No perfect method exists for accurate and reliable avoidance of these catastrophes. This study aimed to study the usefulness of routine intraoperative endoscopy (RIOE) by comparing the surgical outcomes for RIOE patients with those for selective intraoperative endoscopy (SIOE) patients.
  
  
  METHODS
  A retrospective chart review was performed for consecutive patients who underwent elective laparoscopic colorectal resections with distal anastomosis between January 2004 and May 2007. One surgeon performed RIOE, whereas the other three surgeons performed SIOE as necessary. All the abnormalities of IOE patients were managed with a subsequent salvage procedure, and the postoperative outcomes were compared between the RIOE and SIOE groups.
  
  
  RESULTS
  The study included 107 patients in the RIOE group and 137 patients in the SIOE group. Abnormalities were detected in 11 RIOE patients (10.3%) (six with staple line bleeding, three with positive air leak test results, and two with additional pathology identified). All but one abnormality was laparoscopically managed without conversion to laparotomy. Whereas one patient experienced postoperative staple line bleeding that required a second operation, the remaining 10 patients recovered uneventfully. The mean hospital stay was 6 days (range, 4-9) days. The RIOE group had overall rates of 0% for anastomotic leakage and 0.9% for staple line bleeding. Intraoperative endoscopies were performed for 30 (21.9%) of the 137 patients in the SIOE group. The postoperative outcomes comparison between the RIOE and SIOE groups showed a tendency toward more overall anastomotic complications (0.9% vs. 5.1%) in the SIOE group, which due to the small sample size did not translate into significant differences in terms of staple line bleeding and anastomotic leakage. There also were no significant differences in other outcomes such as ileus, abdominal or pelvic sepsis, reoperation, positive distal margin, distance from distal margins, length of hospital stay, or mortality.
  
  
  CONCLUSIONS
  Routine IOE for patients undergoing elective laparoscopic colorectal surgery with distal anastomosis can detect abnormalities at or around the anastomosis. Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced. A larger-scale single or multicenter prospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.
authors.affiliation: Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
authors.forename: Vicky Ka Ming
authors.initials: VK
authors.lastname: Li
authors.forename: Steven D
authors.initials: SD
authors.lastname: Wexner
authors.forename: Nestor
authors.initials: N
authors.lastname: Pulido
authors.forename: Hao
authors.initials: H
authors.lastname: Wang
authors.forename: Hei Yin
authors.initials: HY
authors.lastname: Jin
authors.forename: Eric G
authors.initials: EG
authors.lastname: Weiss
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Nogeuras
authors.forename: Dana R
authors.initials: DR
authors.lastname: Sands
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects* / Q000379:methods; D015331:Cohort Studies; D003107:Colorectal Surgery / Q000009:adverse effects / Q000379:methods*; D017558:Elective Surgical Procedures / Q000009:adverse effects / Q000379:methods; D016099:Endoscopy, Gastrointestinal / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome