title: Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections.
abstract: BACKGROUND
  Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames.
  
  
  METHODS
  This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease.
  
  
  RESULTS
  The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01).
  
  
  CONCLUSIONS
  This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.
authors.affiliation: Department of GI Surgery, PVS Memorial Hospital, Kochi, Kerala, India.
authors.forename: Kurumboor
authors.initials: K
authors.lastname: Prakash
authors.forename: N P
authors.initials: NP
authors.lastname: Kamalesh
authors.forename: K
authors.initials: K
authors.lastname: Pramil
authors.forename: I S
authors.initials: IS
authors.lastname: Vipin
authors.forename: A
authors.initials: A
authors.lastname: Sylesh
authors.forename: Manoj
authors.initials: M
authors.lastname: Jacob
keywords: Case selection; laparoscopic colectomy; learning curve; short-term results
references.citation: Postgrad Med J. 2005 Aug;81(958):537-40
references.pmid: 16085749
references.citation: Dis Colon Rectum. 2001 Feb;44(2):217-22
references.pmid: 11227938
references.citation: Surg Laparosc Endosc. 1991 Sep;1(3):144-50
references.pmid: 1688289
references.citation: Lancet. 2002 Jun 29;359(9325):2224-9
references.pmid: 12103285
references.citation: Lancet Oncol. 2009 Jan;10(1):44-52
references.pmid: 19071061
references.citation: J Clin Oncol. 2007 Jul 20;25(21):3061-8
references.pmid: 17634484
references.citation: J Am Coll Surg. 1998 Jul;187(1):46-54; discussion 54-5
references.pmid: 9660024
references.citation: Surg Endosc. 2006 Jun;20(6):947-51
references.pmid: 16738988
references.citation: Ann Surg. 2007 Oct;246(4):655-62; discussion 662-4
references.pmid: 17893502
references.citation: Ann Surg. 2005 Jul;242(1):83-91
references.pmid: 15973105
references.citation: Lancet. 1994 Jul 2;344(8914):58
references.pmid: 7912321
references.citation: Dis Colon Rectum. 1998 Aug;41(8):963-70
references.pmid: 9715150
references.citation: Surg Endosc. 1998 Sep;12(9):1131-6
references.pmid: 9716766
references.citation: N Engl J Med. 2004 May 13;350(20):2050-9
references.pmid: 15141043
references.citation: Dis Colon Rectum. 2001 Feb;44(2):207-14; discussion 214-6
references.pmid: 11227937
references.citation: Colorectal Dis. 2011 Mar;13(3):267-71
references.pmid: 19930148
references.citation: Indian J Surg. 2010 Aug;72(4):318-22
references.pmid: 21938195