Colorectal Surgery

Catherine Joseph

What is Colorectal Surgery?

Colorectal surgery is the medical specialty that focuses on conditions that affect your colon, rectum, and anus such as inflammatory bowel disease, diverticulitis, and polyps^1,2. There are two main divisions of colorectal surgery³. Abdominal surgeries are performed on the digestive organs in the abdomen, mainly the colon and small intestine³. Examples include procedures for colon cancer and diverticulitis. Whilst anorectal surgeries take place within the anal canal and rectums, examples include treatment for anal fistulas, prolapse, and haemorrhoids ³.

Figure 1: Laparoscopic colon resection ⁴

Figure 2: Different colon diseases ⁵

Notable Journals in the Field

Journal in the Spotlight: Techniques in Coloproctology

“Techniques in Coloproctology” is an international journal focused on epidemiologic, pathologic, diagnostic, and curative studies for colorectal and pelvic floor diseases, showcasing the latest in diagnostic and operative procedures. It covers diverse areas like imaging, clinical physiology, laparoscopy, and open abdominal surgery. As the Official Journal of the Italian Society of Colorectal Surgery (SICCR), it’s crucial for coloproctologists and related specialists⁶.

Article Reviews

Colon Cancer: Laparoscopy or Laparotomy

The mainstay treatment for colon cancer is surgery. Since the introduction of laparoscopic surgery for colon cancer in the early 1990s, the technique has proven to be safe from an oncological perspective with the advantage of faster recovery, less pain, and shorter hospital stays⁶. However, both surgical approaches must follow key cancer treatment principles, including proper tissue removal and lymph node examination. Despite its benefits, laparoscopic surgery adoption varies between countries. In Sweden, its use for colon cancer has increased but is not yet widely adopted compared to open surgery.

This study (taken place in Sweden) aimed to compare laparoscopic and open surgeries for colon cancer across all stages, looking at short-term outcomes like complications, deaths, and cancer removal quality.

Data was collected from the Swedish Colorectal Cancer Registry (SCRCR), which covers 99.8% of diagnosed colorectal cancers in Sweden, and combined with the National Patient Registry (NPR) for 30 and 90-day morbidity and mortality data.

The study included all patients with stage I-IV colon cancer in the right or sigmoid colon, diagnosed between January 2012 and December 2018, who underwent elective colonic resection.

Primary outcome was 30-day mortality, while secondary outcomes included 90-day mortality, re-admissions, re-operations, length of hospital stay, clinical anastomotic leak, positive resection margin (R1), and number of lymph nodes.

Figure 3: Abdominal laparoscopic surgery ⁷

Between 2012 and 2018, a total of 13,683 patients diagnosed with colon cancer stage I–IV underwent colonic resection (removal of all or part of the colon), right hemicolectomy, sigmoid resection, or high anterior resection as recorded in the SCRCR⁶.

Figure 4: Type of colon surgery ⁸ 

Among these patients, 38.1% underwent laparoscopic procedures. Over the study period, there was a significant increase in the use of laparoscopic procedures, rising from 15.4% to 57.2% of all resections. However, despite this increase, the conversion rate from laparoscopic to open surgery remained relatively stable⁶.

The study compared laparoscopic (LAP) and laparotomy (OPEN) surgery outcomes for colon cancer resections:

• The overall 30-day mortality was 1.2%, including 113 patients (1,3%) in the OPEN group and 47 patients (0.9%) in the LAP group. The overall 90-day mortality was 313 (2.3%), 234 (2.8%) in patients who had undergone OPEN surgery, and 79 (1.5%) in LAP surgery.

Concluding that there was no significant difference within 30 days post-surgery, but LAP surgery showed lower mortality rates at 90 days in a weighted analysis.

• Re-operations (Open 7.5% vs LAP 6.0%) and re-admissions were more common in OPEN surgery patients, along with longer hospital stays. A total of 950 patients required one or more re-operations within 30 days.
• A higher proportion of R1 resections meaning cancer cells were found at the edge of the removed tissue, indicating a less complete cancer removal.
• LAP surgery resulted in shorter hospital stays, fewer complications requiring re-operation or re-admission, and a higher rate of complete cancer removals. The study’s strengths include population-based data quality, but limitations such as selection bias were noted.

Ultimately, the study supports LAP surgery as the preferred approach for colon cancer resections due to better short-term outcomes and comparable long-term results to OPEN surgery.

Acknowledgements

This article was brought to you by the TSSS Research Sub-Committee of 2024. The principal author of the piece is Catherine Joseph, with chief editor Ivan Möller overseeing quality.

Bibliography

1. Colorectal surgeon [Internet]. Cleveland Clinic. [cited 2024 May 20]. Available from: https://my.clevelandclinic.org/health/articles/24409-colorectal-surgeon
2. Circlehealthgroup.co.uk. [cited 2024 May 20]. Available from: https://www.circlehealthgroup.co.uk/specialities/colorectal-surgery
3. Andrew M. Breaking down the details of colorectal surgery [Internet]. Mayo Clinic Health System. 2022 [cited 2024 May 20]. Available from: https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/breaking-down-details-of-colorectal-surgery
4. I0.wp.com. [cited 2024 May 20]. Available from: https://i0.wp.com/www.sages.org/wp-content/uploads/2015/03/ColonResection_Page_6.png?ssl=1
5. Cloudfront.net. [cited 2024 May 20]. Available from: https://d2jx2rerrg6sh3.cloudfront.net/image-handler/picture/colon%20disease%20illustration%20-%20Alila%20Medical%20Media%20_thumb.jpg
6. Petersson J, Matthiessen P, Jadid KD, Bock D, Angenete E. Short term results in a population based study indicate advantage for laparoscopic colon cancer surgery versus open. Sci Rep [Internet]. 2023 [cited 2024 May 20];13(1):1–9. Available from: https://www.nature.com/articles/s41598-023-30448-8
7. Diagnostic and advanced laparoscopic surgery [Internet]. Dr. Yogesh Bang – Gastroenterologist In Nagpur | Pancreas Specialist In Nagpur | Oncosurgeon In Nagpur | Laparoscopic Surgeon In Nagpur. Dr. Yogesh Bang Matruchhaya Surgical gastroenterology Clinic; 2019 [cited 2024 May 20]. Available from: https://www.advancedgastrosurgery.com/diagnostic-and-advanced-laparoscopic-surgery/
8. Jaiswal V. Open colectomy procedures [Internet]. Linkedin.com. 2020 [cited 2024 May 20]. Available from: https://www.linkedin.com/pulse/open-colectomy-procedures-vishal-jaiswal