title: Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs.
abstract: BACKGROUND
  Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.
  
  
  METHODS
  Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant.
  
  
  RESULTS
  In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.
  
  
  CONCLUSIONS
  The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. andreluzmoreira@yahoo.com.br
authors.forename: Andre
authors.initials: A
authors.lastname: da Luz Moreira
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
authors.forename: Hasan T
authors.initials: HT
authors.lastname: Kirat
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Geisler
authors.forename: James M
authors.initials: JM
authors.lastname: Church
authors.forename: Thomas
authors.initials: T
authors.lastname: Garofalo
authors.forename: Victor W
authors.initials: VW
authors.lastname: Fazio
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000776:Anesthesiology; D003082:Colectomy / Q000191:economics / Q000379:methods*; D003108:Colonic Diseases / Q000191:economics / Q000601:surgery; D004180:Direct Service Costs / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D007813:Laparotomy / Q000191:economics / Q000379:methods; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000145:classification* / Q000453:epidemiology; D011446:Prospective Studies; D020127:Recovery of Function; D012002:Rectal Diseases / Q000191:economics / Q000601:surgery; D012955:Societies, Medical; D014481:United States / Q000453:epidemiology; D055815:Young Adult