Comparison of Laparoscopic and Open Emergency Surgery for Colorectal Perforation: A Retrospective Study

Kensuke Kudou (  k.k.vermillion0920@gmail.com ) National Kyushu Medical Center Tetsuya Kusumoto National Kyushu Medical Center Sho Nambara National Kyushu Medical Center Yasuo Tsuda National Kyushu Medical Center Eiji Kusumoto National Kyushu Medical Center Rintaro Yoshida National Kyushu Medical Center Yoshihisa Sakaguchi National Kyushu Medical Center Koji Ikejiri National Kyushu Medical Center


Results
The open and laparoscopic groups included 58 and 42 patients, respectively. More than half of the patients in both groups developed perforation in the sigmoid colon (open, 55.2%; laparoscopic, 59.5%).
The most common cause of perforation was diverticulum, followed by colorectal cancer. The mean intraoperative blood loss tended to be lower in the laparoscopic group than in the open group (78.8 mL versus 160.1 mL; P=0.0756). Hospital stay tended to be shorter in the laparoscopic group than in the open group (42.5 versus 55.7 days; P=0.0965). There were no signi cant differences in either the short-or long-term outcomes between the two groups. Univariate and multivariate analyses showed that the choice of surgical approach (open versus laparoscopic) did not affect overall survival in patients with colorectal perforation.

Conclusions
The laparoscopic approach for colorectal perforation in an emergency setting is a safe procedure compared with the open approach. The laparoscopic approach was associated with a decrease in intraoperative blood loss and a shorter length of hospital stay.

Background
In recent years, the usefulness and safety of laparoscopic surgery have been demonstrated in various abdominal surgical procedures, such as cholecystectomy, gastrectomy, and colectomy [1][2][3][4][5][6]. Regarding colorectal diseases, several studies have compared open and laparoscopic surgery under various conditions, such as total colectomy for acute colitis, surgery for colorectal cancers, and colectomy for in ammatory bowel diseases [5][6][7][8][9][10][11]. These studies suggest that the advantages of laparoscopic surgery include earlier recovery of bowel function, a lower incidence rate of postoperative complications, reduced pain scores, decreased estimated blood loss, and shorter hospital stay [6][7][8][9]. However, there are few studies on the e cacy of laparoscopic surgery in an emergency setting. A previous comparative study that examined the laparoscopic approach for emergency colorectal diseases was designed for patients with complicated diverticular disease [12], and another study targeted patients who underwent colectomy regardless of the primary diagnosis [13]. However, data are limited, and the role of the laparoscopic approach under emergency conditions remains controversial. Furthermore, the studies included patients with various conditions, such as colorectal obstruction, hemorrhage, stula, and perforation [12,13].
Therefore, this study focused on colorectal perforation, which can lead to high morbidity and mortality and often causes generalized peritonitis and septic shock. We aimed to clarify the safety and e cacy of laparoscopic surgery for colorectal perforation by comparing the clinical outcomes between laparoscopic and open emergency surgery for colorectal perforation.

Patients
In this retrospective cohort study, we reviewed the data of 372 patients who underwent emergency Moreover, 100 patients were categorized into the cancer group and non-cancer group based on the presence of cancer lesions at the time of perforation. In each group, the abovementioned analyses were performed.
Permission to perform this study was provided by the Institutional Review Board of the National Kyushu Medical Center (20C033). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent to be included in the study or equivalent was obtained from all patients.

Statistical analyses
Differences in characteristics between the groups were evaluated using Fisher's exact test or an unpaired t-test. Survival curves were plotted according to the Kaplan-Meier method, and differences were analyzed using a log-rank test. Univariate and multivariate analyses were performed using a Cox proportional hazards model to identify independent prognostic factors. All P-values were two-sided, and P-value <0.05 was considered statistically signi cant. All analyses were performed using JMP PRO 11 software (SAS Institute Inc., https://www.jmp.com/ja_jp/home.html).

Postoperative survival
The Kaplan-Meier method was used to analyze the overall survival (OS) and to compare the postoperative prognosis between the open and laparoscopic groups (Fig. 1 (Fig. 2). The survival data between open and laparoscopic surgery were compared for patients with cancer and those with other diseases. There were no signi cant differences in 1-year OS rates between the two groups (Fig. 3).

Predictive factors for postoperative survival
Univariate and multivariate analyses showed that the occurrence of postoperative complications (P=0.0075 and 0.0141, respectively) and cancer (versus other diseases) (P=0.0006 and 0.0011, respectively) were independent predictive factors for poorer 1-year OS rates in patients with colorectal perforation. The surgical approach taken (open versus laparoscopic) was not associated with differences in 1-year OS rates in patients with colorectal perforation in both univariate and multivariate analyses (Table 3).

Discussion
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][2][3][4][5][6][7][8][9][10][11][12][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 gastroduodenal 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]. 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 ndings 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 nding 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 di cult 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 signi cant 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 signi cant 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 pro cient 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 ndings obtained from retrospective studies from various institutes would be meaningful. The ndings from the current study may provide useful information regarding the clinical value of the laparoscopic approach for colorectal perforation in an emergency setting.

Conclusions
The laparoscopic approach for colorectal perforation in an emergency setting is a safe procedure when conducted after careful patient selection, and it may decrease intraoperative blood loss and shorten the length of hospital stay. Abbreviations OS, overall survival MST, median survival time Declarations Ethics approval and consent to participate: Permission to perform this study was provided by the Institutional Review Board of the National Kyushu Medical Center (20C033). Informed consent to be included in the study or equivalent was obtained from all patients. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent to be included in the study or equivalent was obtained from all patients.

Consent for publication Not Applicable
Availability of data and material: The data are available upon reasonable request by contacting the corresponding author. Analysis and interpretation of data: K.K., E.K., and Y.S. analyzed the data. K.K. performed statistical analyses. K.K. and T.K. drafted the article. T.K., and Y.S. revised the article critically for important intellectual content. T.K., Y.S., and K.I. approved the nal version of manuscript. All authors have read and approved the manuscript.