This study demonstrated that laparoscopic surgery for colorectal perforation tended to be associated with a reduced amount of intraoperative blood loss and a shorter length of hospital stay. The operative outcomes indicated that the laparoscopic approach could be performed safely in emergency surgery for colorectal perforation with accurate decision-making regarding the indications.
Several studies have compared outcomes between open and laparoscopic approaches for various diseases and conditions [1–13]. Siletz et al. have suggested that laparoscopic surgery is associated with reduced complication rates, shorter operative times, shorter lengths of stay, and lower rates of discharge to skilled nursing facilities for various abdominal conditions, such as gastric perforation, small bowel disease, and ventral hernia [14]. Despite this, Cocorullo et al. have indicated that, for the elderly population, there are no differences in operation times, morbidity rates, and mortality rates between patients undergoing open and laparoscopic approaches for abdominal emergencies, including gastro-duodenal ulcer, small bowel disease, colonic acute disease, cholecystitis, and appendicitis [15]. Thus, these studies demonstrate that the laparoscopic approach can be safely performed even for emergency abdominal surgery [14, 15].
Focusing on the previous reports related to surgery for colorectal disease in the emergency setting, Turley et al. compared laparoscopic and open Hartmann procedures for the emergency treatment of diverticulitis and demonstrated that the laparoscopic approach results in fewer overall complications and a shorter mean length of hospitalization; however, it does not decrease morbidity or mortality [16]. Koh et al. compared the outcomes of laparoscopic colectomies with those of open colectomies under emergency conditions, such as colorectal bleeding, obstruction, and perforation, and demonstrated that the operative times in laparoscopic colectomies were longer than those in open colectomies, while the duration of hospitalization and postoperative morbidity between the two groups were similar [13]. Letarte et al. compared the perioperative outcomes of laparoscopic colon resection and open colon resection for the treatment of complicated diverticular disease in the emergency setting, and they suggested that laparoscopic surgery was associated with decreased morbidity, intraoperative blood loss, time to oral intake, and length of hospital stay, while the mean operative time was longer than that of the open approach [12].
The above studies targeted colorectal disease with indications for emergency surgery, and they included various conditions, such as perforation, hemorrhage, and obstruction. The differences among these conditions are important and may substantially affect surgical procedures or perioperative outcomes. Notably, colorectal perforation has an extremely poor prognosis due to generalized peritonitis and sepsis, and it often requires extensive drainage. Therefore, this study only focused on colorectal perforation. Our findings on intraoperative blood loss and hospital stay were similar to those reported previously. Most previous studies have demonstrated that the laparoscopic approach requires longer operative times [12, 13], whereas our study showed that the mean operative times were not different between the open and laparoscopic groups. This finding might be related to the patients in our study, who had all received a diagnosis of colorectal perforation and who were usually in poor general condition and required urgent surgery. Consequently, decisions to convert to open surgery for patients in whom it was difficult to complete laparoscopic surgery may have been made faster than for those with other diseases.
This study focused on the causes of colorectal perforation, i.e., malignant or benign diseases, because they might affect the prognosis. Indeed, there were significant differences in the prognoses of patients with and without cancer. Moreover, in patients with cancer, progression of the primary cancer may be associated with their prognoses. In this study, both the cancer and other disease groups demonstrated no significant differences in 1-year OS rates between the open and laparoscopic approaches.
This study had a few limitations. A main limitation of our study was selection bias. The surgical procedure chosen, namely, an open or a laparoscopic approach, was dependent on each surgeon’s decision. Consequently, surgeons who are proficient in laparoscopic surgery may tend to select the laparoscopic approach for wider indications, and choices of the surgeons may affect surgical and postoperative outcomes. In addition, this was a single-institution retrospective study that included a small sample size. Patients in this study were diagnosed with colorectal perforation and underwent emergency surgery; therefore, it was impossible to avoid selection bias or to design a prospective study. A comparison of the findings obtained from retrospective studies from various institutes would be meaningful. The findings from the current study may provide useful information regarding the clinical value of the laparoscopic approach for colorectal perforation in an emergency setting.