infecciones CIRUGIA COLORECTAL.pdf

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ORIGINAL ARTICLES

A Multivariate Analysis of Potential Risk Factors for Intra- and Postoperative Complications in 1316 Elective

Laparoscopic Colorectal Procedures

Philipp Kirchhoff, MD, Selim Dincler, MD, and Peter Buchmann, MD

Objective: To identify predictive risk factors for intra- and postop-

erative complications in patients undergoing laparoscopic colo-

rectal surgery.

Background Data: In emergency situations or in elective open and

laparoscopic colorectal surgery, there are many risk factors that

should be recognized by the surgeon to reduce complications and initiate adequate treatment. Most available data, thus far, refer to

open colorectal surgery and literature that focuses mainly on a

laparoscopic approach is still rare.

Methods: Univariate and multivariate analyses of a prospectively

gathered database (1993–2006) were performed on a consecutive

series of patients (1316) undergoing laparoscopic colorectal sur-

gery who were operated at a single institution (first referral

center). Patients were assessed for demographic data, operative

indications, type of resection, and intra- and postoperative com-

plica tions. Altogether, we analyzed 20 potential risk factors to

identify significant influence on the intra- and postoperative

outcome.

Results: Significant risk factors that led to intraoperative complica tions consisted of age 75 years and malignant neoplasia.

Increased postoperative rate of surgical complications was sig-

nificantly influenced by male gender, age 75 years, American

Society of Anesthesiology class III, malignant neoplasia, and

the experience of the surgeon. The analysis of specific medical

postoperat ive compl icati ons revealed even more signi ficant pre-

dictive risk factors. In addition, our analysis showed that specific

risk factors predict specific complications such as postoperative

bleeding, anastomoti c leakage, and surgical site infections. The

type of surgical procedure performed also influenced patient

outcome.

Conclusion: This large single center study provides the first evi-

dence of the significance of predictive risk factors for intra- and postoperative complications in laparoscopic colorectal surgery.

( Ann Surg 2008;248: 259–265)

To date, most studies of laparoscopic colorectal procedureshave been descriptive reports that do not account for the potentially complex interaction of outcome predictors. Manyrecent studies have shown that the laparoscopic approach incolorectal surgery is well established and more feasible incomparison with the open access techniques. Numerous stud-ies show the advantages of laparoscopic colorectal surgerysuch as reduced need for analgesics, faster onset of postop-erative activity, less wound infections, and shorter length of hospital stay.1,2 The decision to perform a laparoscopic in-tervention remains challenging and the risk of complicationsmust be weighed against the advantages of reduced invasive-ness. Although there is no difference in mortality betweenlaparoscopic and open colorectal surgery, the conversion ratein the laparoscopic approach is up to 30% and leads to anincreased operating time but similar treatment costs.3–5 Al-though it is well proven that laparoscopic surgery can be performed efficiently for a broad spectrum of diseases affect-ing the gastrointestinal tract, it is still necessary to evaluate

the best surgical treatment in every individual case. Surgeonsuse many factors to determine whether a patient will toleratea particular surgical procedure. The decision until now hasmostly been based on intuition and knowledge of the relativerisk of the operation itself. Therefore, there is a strong need to provide the surgeon with more objective means of assessmentfor individual patients to choose the best surgical procedure.Intra- and postoperative complications might occur in pa-tients at risk. Many criteria determining this risk have been proposed, but to date, there is no large and well-designed study to confirm these predictive risk factors especially inlaparoscopic colorectal surgery.

Scoring systems to predict morbidity and mortality

from surgery are important tools used to give information tothe surgeon and patient. The existing scoring systems incolorectal surgery are CR-POSSUM (colorectal physiologicand operative severity score for enumeration of mortality and morbidity), AFC (4-item predictive score of mortality after colorectal surgery), and the Cleveland Clinic Foundationcolorectal cancer model. Most of these scoring systems arelacking in feasibility, accuracy, and predict only mortality,not morbidity.6

To date, there is no scoring system predicting compli-cations in laparoscopic colorectal procedures. Even studiesevaluating predictive risk factors for complications in opencolorectal surgery are rare and mainly small in sample size.

From the Department of Surgery, City Hospital Waid, Zurich, Switzerland.First two authors contributed equally to this work.Reprints: Peter Buchmann, MD, Department of Surgery, City Hospital

Waid, Tièchestrasse 99, 8037 Zurich, Switzerland. E-mail: peter. buchma [email protected] .ch.

Copyright © 2008 by Lippincott Williams & WilkinsISSN: 0003-4932/08/24802-0259DOI: 10.1097/SLA.0b013e31817bbe3a

Annals of Surgery • Volume 248, Number 2, August 2008 259


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In this study, we analyzed 20 parameters from a pro-spective data collection (1993–2006) of 1316 patients under-going laparoscopic colorectal surgery and their influence onthe intra- and postoperative complications.

PATIENTS AND METHODS

A consecutive series of patients undergoing laparo-scopic colorectal surgery from 1993 through 2006 was pro-spectively entered into a database in the Department of Surgery at the City Hospital Waid, Zurich, Switzerland. CityHospital Waid is a teaching hospital and provides training ingeneral surgery and laparoscopic techniques. A total of 1316colorectal procedures were performed during this 13-year period. The different diagnoses and performed surgical pro-cedures are listed in Tables 2 and 3. The population of thisstudy consisted of patients with an age range from 13 to 94(mean, 64.2 years), undergoing laparoscopic colorectal sur-gery. The operations were performed by 13 different sur-geons. Two of them did 889 surgical interventions of the

1316. In addition to the listed procedures, we also performed surgeries such as cholecystectomy, adnexectomy, appendec-tomy when indicated intraoperatively. Data recorded for each patient included age, sex, body mass index, indication for surgery, performed surgical procedure, surgeon’s experience,conversion to laparotomy, length of operation, intra- and postoperative complications, American Society of Anesthe-siology (ASA) score, preoperative hemoglobin, length of hospital stay, tumor classification, mortality, neoadjuvantradio/chemotherapy, reoperation, and multiple comorbiditiesaccording to the Charlson Index such as diabetes mellitus,history of heart failure or myocardial infarction, chronicobstructive pulmonary disease, cirrhosis, renal insufficiency,dementia, AIDS, leucemia, and vascular disease. The demo-graphic and clinical data are given in Table 1.

We recorded intraoperative complications such as bowelinjury, urethral injury, bleeding, anastomotic problems, and anesthesiologic complications. Anastomotic problems, bowel,and urethral injury were defined as problems in which further surgical procedures were needed. Bleeding as a complicationwas recorded when additional treatment such as blood transfu-sion, vascular surgery, or conversion to open surgery was ap- plied. Anesthesiologic complications were included, when anyadditional treatment of the anesthesiologist or conversion due toanesthesiologic complications was necessary.

Postoperative complications were differentiated into sur-gical complications such as bleeding, abscess, anastomotic in-sufficiency, surgical site infection or wound dehiscence, and medical complications such as pneumonia, pulmonary embolus,thrombosis, cardiac failure or infarction, and renal failure. Post-operative bleeding was recorded if reoperation was necessary or

a blood transfusion was given. Abscess was defined by detectionthrough ultrasound or CT scan followed by reoperation, antibi-otic therapy, or CT-guided drainage. Anastomotic insufficiencydiagnosed by CT scan and treated either with antibiotics or reoperation was included. Surgical site infection was defined byclinical signs and open-wound treatment with or without antibi-otic usage. Deep wound dehiscence was recorded if surgicalreintervention was necessary. Medical complications were in-cluded if diagnosed clinically and verified by objective diagnos-tics and/or additional medical treatment.

To identify potential predictive risk factors for intra-and postoperative complications, we used univariate and multivariate analysis. We separately analyzed medical and

surgical complications and their influence by the preopera-tive-recorded parameters. Here, we also looked in detail if the parameters could predict specific surgical complications. Inaddition, we calculated the complication rate for each per-formed surgical procedure.

StatisticsStatistical analysis was performed using the SPSS sta-

tistical software package (SPSS Inc.; Chicago, IL). Theunivariate relation between each independent variable and intra- and postoperative complications was evaluated using alogistic model for continuous variables and Pearson 2 testfor categorical variables. Independent variables with a P value 0.05 in the univariate analysis were entered into the

multivariate logistic regression model. P values 0.05 wereconsidered to be statistically significant.

RESULTSBetween 1993 and 2006, 1316 laparoscopic colorectal

procedures were performed at our department. The mean patient age was 64.2 14.65 years (range, 13–94). Therewere 790 women (60%) and 526 men (40%); the mean BMIwas 25.1 4.38. The mean duration of hospitalization was10.5 7.7 days. Patient demographic data are shown inTable 1 and the indications for surgery are shown in Table 2.

TABLE 2. Indications of Laparoscopic Colorectal Procedures

Diagnosis N (%)

Carcinoma 463 (35.1)

Diverticulosis 361 (27.4)

Acute diverticulitis 189 (14.4)

Prolapse 121 (9.2)

Polyps 71 (5.5)

IBD 44 (3.3)

Outlet obstruction 23 (1.7)

Other 44 (3.3)

IBD indicates inflammatory bowel disease.

TABLE 1. Demographics and Clinical Characteristics of Patients

Age (yrs) 64.2 14.65

Men/woman (n) 526/790

BMI 25.14 4.38

Obesity BMI 30 167 (12.7%)

Malnutrition BMI 17 18 (1.4%)

Cancer/benign disease 463 (35.1%)/853 (64.9%)

Operating time (min) 205.51 73.09

Hemoglobin (g/L) 133.5 16.1

Length of stay (d) 10.5 7.7

BMI indicates body mass index.

Kirchhoff et al Annals of Surgery • Volume 248, Number 2, August 2008

© 2008 Lippincott Williams & Wilkins260


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The most common procedure was sigmoid resection in562 patients. In 180 cases, low anterior resections were per-formed both for diverticular disease and rectal cancer. Rectosig-moid resections were performed in 94 cases, most of them for benign diseases where the upper third of the rectum and thesigmoid was involved. Rectum resection (68) was defined asresection of the mid and upper part of the rectum. Proctocolec-tomy was performed in 21 patients and 134 patients underwentlaparoscopic hemicolectomy (116 right and 18 left). In 102cases, a simultaneous rectopexy with sigmoid resection was performed, whereas a laparoscopic sutured vaginal retrofixationwas carried out in 26 patients. Laparoscopic excision of therectum was done in 49 patients because of rectal cancer (Table 3).

The data show that the type of colon procedure had

significant influence on the intra- and postoperative compli-cation rates. Although the overall intraoperative complicationrate was 7.4%, the complications during low anterior resec-tion (17.2%), rectum amputation (14.6%), and proctocolec-tomy (19%) were much higher. These results are comparablewith data from the literature and can be explained by thecomplexity of the surgical procedure and the severity of underlying diseases. The specific postoperative rate of surgi-cal (16.2%) und medical (8.7%) complications for eachsurgical procedure is also shown in Table 3. The postopera-tive surgical complication rate after proctocolectomy(33.3%), low anterior resection (34.4%), and rectum ampu-tation (30.6%) is much higher than the average. Concerning

the medical postoperative complication rates (8.7%), thecomplex surgical procedures did not show higher complica-tion rates except the rate after low anterior resection that wassignificantly higher (15%). Cecum resection and retrofixationvaginae had no medical complications at all.

Intraoperative complications were observed in 97 pa-tients (7.4%). There were 27 bowel lesions, 17 bleedingepisodes, 15 urethral injuries, 16 anastomotic problems, and 11 anesthesiological complications documented. In 4 casesmore than 1 intraoperative complication occurred and 7 other complications were documented.

Altogether, 327 postoperative complications occurred in289 patients (morbidity 22%). The most common surgical com-

plications were anastomotic leakage, surgical site infections, and postoperative bleeding. Pneumonia and cardiac insufficiencywere the major medical complications. The 30-day mortalityrate was 1.8% (24 patients). The detailed intra- and postopera-tive complications are listed in Tables 4 and 5.

Tables 6 and 7 show the perioperative factors recorded prospectively from 1993 to 2006. These factors were ana-

TABLE 3. Performed Surgical Procedures and Specific Complication Rates

Surgical Procedures N (%)

Intraoperative

Complications, N (%)

Postoperative Complications,

(Surgical; Medical), N (%)

Sigma resection 562 (42.7) 28 (5.0) 66 (11.7); 43 (7.7)

Low anterior resection 180 (13.7) 31 (17.2) 62 (34.4); 27 (15)

Right hemicolectomy 116 (8.8) 1 (0.9) 18 (15.5); 12 (10.3)Sigma resection plus rectopexy 102 (7.8) 5 (4.9) 11 (10.8); 7 (6.9)

Rectosigmoid resection 94 (7.1) 11 (11.7) 7 (7.4); 8 (8.5)

Rectum resection 68 (5.2) 4 (5.9) 11 (16.2); 7 (10.3)

Rectum amputation 49 (3.7) 7 (14.6) 15 (30.6); 4 (8.2)

Coecum resection 32 (2.4) 0 (0) 4 (12.5); 0 (0)

Retrofixation vaginae 26 (2.0) 1 (3.8) 1 (3.8); 0 (0)

Proctocolectomy 21 (1.6) 4 (19.0) 7 (33.3); 2 (9.5)

Left hemicolectomy 18 (1.4) 1 (5.6) 3 (16.7); 1 (5.6)

Other 48 (3.6) 4 (0.08) 8 (16.6); 3 (6.25)

Overall 1316 (100) 97 (7.4) 213 (16.2); 114 (8.7)

TABLE 4. Intraoperative Complications, N (%)

Intraoperative complications 97 (7.4)

Bowel injury 27 (32.1)

Urethral injury 15 (15.4)

Bleeding 17 (20.2)

Anastomotic problems 16 (19)Anesthesia problems 11 (13.1)

More than 1 complication 4 (4.8)

Other 7 (8.4)

TABLE 5. Postoperative Complications, N (%)

Surgical complications 213 (16.2)

Anastomotic leakage 59 (27.7)

Surgical site infection 49 (23)

Bleeding 29 (13.6)

Douglas abscess 13 (6.1)

Perineal abscess 11 (5.1)

Wound dehiscence 12 (5.6)

Other 29 (13.6)


Medical complications 114 (8.7)

Pneumonia 49 (42.9)

Cardiac complications 29 (25.4)

Pulmonary embolism 7 (6.1)

Deep vein thrombosis 2 (1.8)

Other 19 (16.6)


Overall morbidity 289 (22)

Overall mortality (30 d) 24 (1.8)

Annals of Surgery • Volume 248, Number 2, August 2008 Complications in Laparoscopic Colorectal Procedures

© 2008 Lippincott Williams & Wilkins 261


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TABLE 6. Risk Factors for Overall Intra- and Postoperative Complications*

Variables n

IntraoperativeComplications

Postoperative

ComplicationsOverall

% P % P

Experience 70/70 cases 872 19.9/26.1 0.01Age 75 yr 335 11.4 0.001 29.6 0.001

BMI 30 167

BMI 17 18

Gender (female/male) 790/526 6.2/9.1 0.048 17.0/29.5 0.001

ASA score III 305 10.5 0.020 30.4 0.001

pT status 289

pN status 289

Liver disease 26

Diabetes 57

Anemia HB 12 g/L 241 29.5 0.002

Prior myocardial infarct 55 32.7 0.049

Prior heart failure 167 31.1 0.002

Vascular disease 78Cerebrovascular disease 36

Dementia 17

Chronic lung disease 57

Renal insufficiency (Creatinine 260 mol/L) 6

Neoplasia 413 12.1 0.001 31.4 0.001

Metastasis of a solid tumor 54

*Empty cells are not significantly predictive for intra- and/or postoperative complications.ASA indicates American Society of Anesthesiology; BMI, body mass index.

TABLE 7. Risk Factors for Medical and Surgical Postoperative Complications

Variables n

Postoperative SurgicalComplications

Postoperative MedicalComplications

% P % P

Experience 70/70 cases 872 7.2/11.5 0.007

Age 75/75 yr 335 6/16.1 0.001

BMI 30/30 167 15.2/23.4 0.007

BMI 17 18

Gender (female/male) 790/526 11.3/23.6 0.001 7.2/10.8 0.015

ASA Score III/III 305 14.6/20.9 0.007 7.2/13.7 0.001

pT-status 289

pN status 289

Liver disease 26

Diabetes (no/yes) 57 8.3/15.8 0.05

Anemia HB 12/12 g/L 241 7.0/16.2 0.001

Prior myocard infarct (no/yes) 55 8.2/18.2 0.01

Prior heart failure (no/yes) 167 15.4/21.6 0.032 7.4/17.4 0.001

Vascular disease (no/yes) 78 8.1/16.7 0.009

Cerebro vascular disease 36

Dementia 17

Chronic lung disease (no/yes) 57 8.3/15.8 0.05

Renal insufficiency (no/yes) 6 8.5/33.3 0.031

Neoplasia (no/yes) 413 12.8/23.7 0.001 6.8/12.6 0.01

Metastasis of a solid tumor 54




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lyzed in a univariate and multivariate way to detect their influence on intra- and postoperative complications.

Univariate AnalysisWhereas between the surgeons, there was no difference

concerning intra- and postoperative results, the experienced

surgeons (

70 laparoscopic procedures) had significantly less postoperative complications (19.9% in the experienced group vs.26.1% in the less experienced group). Intraoperative complica-tions did not differ significantly between these groups.

Patients older than 75 years had overall more intra- and postoperative complications than younger patients. Obese patients (BMI 30) had significant higher surgical compli-cations. Malnourished (BMI 17) patients were not at ahigher significant risk for intra- and postoperative complica-tions. Both intra- and postoperative complications occurred more often in men than in women (intraoperative complica-tions 9.1% vs. 6.2%, postoperative complications 29.5% vs.17%) in the univariate analysis. Although classes I to IV of the ASA score were separately not observed as significant for

intra- or postoperative complications, the patient group thatgraded ASA class III and higher were at significant risk todevelop intraoperative problems and postoperative surgicaland medical complications in comparison with the patientsranked lower than ASA class III. Different tumor progressionrates and lymph node status had no influence on the postop-erative 30-day follow-up.

Preoperative anemia (HB 12 g/L), prior heart failure,and history of myocardial infarction had significant influenceon postoperative outcome, although intraoperative complica-

tions were not influenced. Only prior heart failure had sig-nificant influence on postoperative surgical complication rate.Interestingly, renal insufficiency and presence of vascular disease led to significant medical postoperative problems.Chronic lung disease and diabetes also had the tendency to causemore postoperative medical problems ( P 0.05). The diagnosis

of a neoplasia increased intra- and postoperative complicationrates significantly. Hepatic diseases, cerebrovascular disease,and dementia seemed to have no influence on the intra- or postoperative course (data shown in Tables 6 and 7).

In Table 8 significant predictive parameters for specific postoperative surgical problems are listed. Male patients are atsignificant higher risk of postoperative bleeding ( P 0.013).BMI 30 ( P 0.001), male gender ( P 0.001), and presenceof neoplasia ( P 0.001) are predictive for postoperative anas-tomotic leakage. Surgical site infection is only increased signif-icantly in patients older than 75 years ( P 0.04).

Multivariate Analysis

After univariate analysis, those variables with a P valueless than 0.05 were selected for multivariate analysis using astepwise logistic regression model. Table 9 summarizes theresults of the multivariate analysis. Patients older than 75years and presence of neoplasia were predictive of develop-ing intra- and postoperative complications in laparoscopiccolorectal surgery. Additionally ASA class III, male gen-der, and lack of surgical experience (70 procedures) alsowere independent predictors for postoperative outcome.

DISCUSSIONThe feasibility and safety of laparoscopic colorectal

surgery has been reported numerous times in current surgical

literature. The standard of quality and improvements in the perioperative clinical course should always be taken intoconsideration by the surgical team. The perioperative period can be more successful if we know which factors haveinfluence on the patient’s outcome. Therefore, there exists aneed to provide the surgeon with an objective means of assessment for individual patients especially in laparoscopiccolorectal surgery.

In our series of 1316 patients, using a univariate and multivariate analysis, we examined 20 perioperative factorsand defined risk factors, which proved to be significant in predicting an increase of intra- and postoperative complica-tions. These included in the multivariate analysis the age 75

TABLE 8. Specific Variables and Related Surgical

Postoperative Complications

Variables

BleedingAnastomotic

Leakage

Surgical

SiteInfection

% P % P % P

Age 75/75 yr 2.9/6.3 0.04

BMI 30/30 3.9/8.4 0.001

Gender (female/male)

1.4/3.4 0.013 2.3/7.8 0.001

Malignantneoplasia(no/yes)

2.4/8.9 0.001

TABLE 9. Multivariate Logistic Regression Analysis of Variable Associated WithIntra- and Postoperative Complications

Variable

Intraoperative Complications Postoperative Complications

OR 95% CI P OR 95% CI P

Experience 70 cases 0.72 0.54–0.95 0.024

Age 75 yr 1.69 1.09–2.62 0.019 1.57 1.15–2.13 0.004

Male gender 0.109 1.99 1.50–2.62 0.001

ASA III 0.217 1.48 1.08–2.01 0.012

Neoplasia 1.5 1.20–1.80 0.001 1.31 1.13–1.51 0.001

CI indicates confidence interval; OR, odds ratio; ASA, American Society of Anesthesiology.




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years, experience of the surgeon, male gender, ASA scoreIII, and neoplasia. The overall morbidity in our patient population was 22%, and the mortality rate was 1.8%. In theliterature, morbidity rates for laparoscopic colorectal surgeryof between 6% and 31% are reported, and are thus compa-rable with our data. This also applies to the reported mortality

rates that vary between 0% and 4.5% in the published literature.7,8

No large study has been conducted to investigate therisk factors for perioperative complications undergoing lapa-roscopic colorectal surgery and until now most studies haveconcentrated on a few factors with small sample sizes. Alsothe influence of the patient’s weight on perioperative complication rates in open and laparoscopic major visceral sur-gery was extensively examined but the results are still con-troversial.9,10 Here, we show that obesity (BMI 30) hasincreased the risk of surgical postoperative complicationssuch as anastomotic leakage but interestingly has no influenceon medical complication and intraoperative outcome. Moloo

et al11

showed that obese patients have a higher conversionrate to open surgery, although the converted cases seem not tohave higher morbidity rates than the laparoscopically finished cases. In open colorectal surgery, preoperative risk factorssuch as emergency operation, age 75 years, abdominalradiation, hypoalbuminemia, COPD, prior MI, and diabetesmellitus were already validated in 1992.12 In our study, prior myocardial infarction, chronic lung disease, and renal insuf-ficiency only increases the risk for medical complications butdid not influence the rate of postoperative surgical complica-tions. However, none of the studies differentiated betweenintra- and postoperative complications and medical and sur-gical problems, which is important for the outcome and

therefore guiding the surgical team.One large study on 1421 patients aimed at identifying

risk factors for postoperative complications combined datafrom open and laparoscopic surgery. They found that pa-tient’s age (70 years), neurologic or cardiopulmonary co-morbidity, hypoalbuminemia, long duration of operation, and peritoneal contamination independently increased the risk of postoperative complications. Recently, the same group pub-lished a score (AFC-score), which is a pertinent predictivescore of postoperative mortality after colorectal surgery.Despite the interesting results and feasibility of this score, itdoes not include morbidity and gives no information aboutintraoperative risk factors.13,14 Longo et al concluded that

patients with an ASA class

III, serum sodium

145mmol/L, and ascites had an increased morbidity or mortalityrate after colectomy.15,16 Because of a recently published study by our group that evaluates predictive factors for complications in laparascopic colorectal surgery by an expertsurvey on patients with liver cirrhosis and renal failure, whichshowed a strong association with high perioperative risk,although this has to be evaluated in a further analysis.17 In our hospital, patients suffering from liver and renal failure werefew. This might be a reason that these factors in our institu-tion are not significantly increasing the perioperative morbid-ity in our study. Hospitals having more HPB cases or patientswith renal failure undergoing laparoscopic colorectal surgery

might observe a correlation of increased perioperative complication rates.

Because in our multivariate analysis, the predictivefactors such as age, neoplasia, gender, and ASA class IIIcannot be influenced perioperatively, it helps the surgeon to be aware of increased risk and therefore choose the safest

treatment for the patient. The experience of the surgeon playsa significant role in complex cases. This fact favors a well-trained surgeon rather than a teaching operation for a resi-dent. Interestingly, the univariate analysis revealed 11 pre-dictive risk factors for medical complications. Preoperativeanemia should be corrected and also diagnostic and improve-ment of decompensated comorbidities should be properlyadjusted before elective surgery to minimize risk. In addition,the different risk factors should be kept in mind before the planned surgical procedure (eg, proctocolectomy) so as not to potentiate the risk for perioperative complications.

In conclusion, this study provides the first evidence of predictive risk factors for intra- and postoperative complica-

tions in patients undergoing laparoscopic colorectal surgeryand differentiation of medical from surgical complications.Also, it shows for the first time influencing risk factors on theintraoperative course in surgery. This might help the surgeonin making perioperative decisions and could indicate that anexperienced surgeon should be involved in the decisionmaking progress and during the operation so as to lower the patients risk and improve the outcome. As patient outcome isnever predictable, these data should help to elucidate thequite complex interactions and may lead the surgeon to afeasible and simple score that helps to minimize risk and maximize the patient’s benefit from laparoscopic colorectalsurgery.

REFERENCES1. Lezoche E, Feliciotti F, Guerrieri M, et al. Laparoscopic versus open

hemicolectomy. Minerva Chir . 2003;58:491– 497.2. Scala A, Huang A, Dowson HM, et al. Laparoscopic colorectal sur-

gery—results from 200 patients. Colorectal Dis. 2007;9:701–705.3. Pokala N, Delaney CP, Senagore AJ, et al. Laparoscopic vs open total

colectomy: a case-matched comparative study. Surg Endosc. 2005;19:531–535.4. Dowson HM, Huang A, Soon Y, et al. Systematic review of the costs of

laparoscopic colorectal surgery. Dis Colon Rectum. 2007;50:908–919.5. Wahl P, Hahnloser D, Chanson C, et al. Laparoscopic and open colo-

rectal surgery in everyday practice: retrospective study. ANZ J Surg .2006;76:20–27.

6. Bromage SJ, Cunliffe WJ. Validation of the CR-POSSUM risk-adjusted scoring system for major colorectal cancer surgery in a single center. DisColon Rectum. 2007;50:192–196.

7. Degiuli M, Mineccia M, Bertone A, et al. Outcome of laparoscopiccolorectal resection. Surg Endosc. 2004;18:427– 432.8. Schwenk W, Haase O, Neudecker J, et al. Short term benefits for

laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;CD003145.

9. Gendall KA, Raniga S, Kennedy R, et al. The impact of obesity onoutcome after major colorectal surgery. Dis Colon Rectum. 2007;50:2223–2237.

10. Lascano CA, Kaidar-Person O, Szomstein S, et al. Challenges of laparoscopic colectomy in the obese patient: a review. Am J Surg .2006;192:357–365.

11. Moloo H, Mamazza J, Poulin EC, et al. Laparoscopic resections for colorectalcancer: does conversion survival? Surg Endosc. 2004;18:732–735.

12. Ondrula DP, Nelson RL, Prasad ML, et al. Multifactorial index of preoperative risk factors in colon resections. Dis Colon Rectum. 1992;35:117–122.




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13. Alves A, Panis Y, Mantion G, et al. The AFC score: validation of a4-item predicting score of postoperative mortality after colorectal resec-tion for cancer or diverticulitis: results of a prospective multicenter studyin 1049 patients. Ann Surg . 2007;246:91–96.

14. Alves A, Panis Y, Mathieu P, et al. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study. Arch Surg. 2005;140:278 –283; dis-cussion 284.

15. Yoo PS, Mulkeen AL, Frattini JC, et al. Assessing risk factors for adverseoutcomes in emergent colorectal surgery. Surg Oncol . 2006;15:85–89.

16. Longo WE, Virgo KS, Johnson FE, et al. Risk factors for morbidityand mortality after colectomy for colon cancer. Dis Colon Rectum.2000;43:83–91.

17. Dincler S, Bachmann LM, Buchmann P, et al. Predictors of intra- and postoperative complications in laparoscopic colorectal surgery: resultsof an expert survey. Dig Surg . 2006;23:110–114.



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