Laparoscopic Colectomy Is an Underused Procedure for the Elective Management of Colovesical Fistulas

Colovesical fistulas are a complex condition often presenting as a complication of diverticulitis, colon cancer, or Crohn's disease. Colovesical fistulas are the most common type of fistulas associated with diverticular disease, representing 65 per cent of this group.1 The treatment of this type of fistula has traditionally consisted of open colectomy (OC), often requiring a complicated pelvic dissection. Early attempts to use laparoscopy for the treatment of this entity resulted in high conversion rates and prolonged operative time. We sought to analyze the role and contemporary use of laparoscopic colon resection for the treatment of colovesical fistulas using a nationwide patient database.

A retrospective analysis of the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project for the years 2008 and 2009 was performed to identify our population. International Classification of Diseases, 9th Revision (ICD-9) codes were used to identify patients electively admitted with a diagnosis of colovesical fistula (596.1) and diverticulitis of the colon (562.10, 562.11), colon cancer (153.0 to 153.9), or Crohn's disease of the large intestine (555.1). ICD-9 procedural codes were then used to select patients who underwent OC (45.73, 45.75, 45.76) or laparoscopic colectomy (LC) (17.33, 17.35, 17.36). Laparoscopic procedures converted to open were identified by the ICD-9 code V64.41 and included in the OC group for analysis. Patient demographics, hospital teaching status, and number of chronic conditions were analyzed in the two groups. Patient outcomes including mortality rate, in-hospital complication rate, conversion rate, ostomy creation rate, length of stay, and total hospital charges were compared between the two groups.

Data were analyzed using Statistical Package for the Social Sciences (SPSS) software (IBM SPSS Statistics Version 20; SPSS Inc.Chicago, IL). Categorical variables were compared using Pearson's x2 and continuous variables were compared using Student's t test. A multivariate logistic regression model was created to identify independent risk factors for the development of in-hospital complications and the use of laparoscopy. A P value of < 0.05 was considered to be statistically significant.

During this period, a total 6301 patients underwent elective colon resection for colovesical fistula. Of this group, only 17 per cent of these were performed laparoscopically. Conversion to an open procedure was reported in 5.5 per cent of these cases. Median age of the population was 62 years old (range, 1895 years), 62 per cent were male, 76 per cent were white, and 47 per cent had private insurance. The diagnosis of colovesical fistula was secondary to diverticulitis in 93.4 per cent of the cases, colon cancer in 5.4 per cent, and Crohn's disease of the colon in 1.2 per cent.

Mean length of stay was longer in the OC group, 8.4 versus 5.9 days (P < 0.001), and there was a trend toward higher mean total hospital charges in the OC group, $59,582 versus 53,869 (P 4 0.06), but this did not reach statistical significance. Mortality rate was 1.1 per cent in the open group and there were no deaths reported in the laparoscopic group (P < 0.001). Stoma formation was higher in the OC group, 12.8 versus 4.0 per cent (P < 0.001).

The overall in-hospital complication rate was lower in the LC group, 13.2 versus 19.5 per cent (P < 0.001). The total number of infectious (2.4 vs 6.0%), woundrelated (5.2 vs 15.6%), and pulmonary complications (1.3 vs 0%) was lower in the LC group (P < 0.001). There was no statistically significant difference in the rate of gastrointestinal, cardiovascular, or urinary complications.

Risk factors associated with the development of inhospital complications included the presence of four or more chronic conditions (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1 to 1.4; P 4 0.01), not having private insurance (OR, 1.2; 95% CI, 1.1 to 1.4; P 4 0.01), and having undergone an OC (OR, 1.5; 95% CI, 1.2 to 1.8; P < 0.001). Independent variables identified favoring the use of LC were colovesical fistula of diverticular origin (OR, 2.2; 95% CI, 1.7 to 2.8; P < 0.001), female gender (OR, 1.2; 95% CI, 1.1 to 1.4; P 4 0.04), and white race (OR, 1.3; 95% CI, 1.1 to 1.5; P < 0.001).

LC has been adopted very slowly when compared with other minimally invasive procedures such as laparoscopic cholecystectomy. Since its original description in 1991, multiple publications have proven LC as a feasible and safe alternative to open colectomy. 2, 3 Nonetheless, in 2001, 10 years after its original description, it was estimated that only 3.6 per cent of colon resections were being performed laparoscopically. 3 Recent studies have demonstrated that the number of laparoscopic colon resections has increased over the past 10 years, representing up to 38 per cent of the colonic resections performed today.3 When our results are compared with other populationbased analyses of patients undergoing colectomy,2, 3 patients with a diagnosis of colovesical fistula were less likely to undergo LC. This highlights the fact that LC is an underused resource in this patient population despite the publication of multiple reports that have demonstrated that the benefits of LC for complex benign disease persists with lower morbidity rates, shorter length of stay, and lower hospital costs,3 conclusions reaffirmed by our analysis of this patient population at the national level.

There are only a few studies focusing on the laparoscopic management of colovesical fistulas with reported conversion rates of 5.0 to 14.3 per cent.4 We report a conversion rate of 5.5 per cent, which is at the lower end of the spectrum of reports from the literature. This finding could be secondary to the fact that surgeons are now more proficient in the use of advanced laparoscopic techniques and our study includes more recent data.3 The low conversion rates in our analysis could also be secondary to underreporting by the surgeon or as a result of miscoding, because the definition of conversion to an open procedure is not clearly defined in the ICD-9-Clinical Modification manual and varies from surgeon to surgeon.

This study is subject to the limitations inherent to all retrospective studies using national administrative databases. Physiologic and laboratory data and intraoperative details are lacking in the database. Despite these limitations, our findings offer useful insight into the contemporary outcomes of patients who underwent colectomy for colovesical fistulas specifically in the recent era in which laparoscopic colon surgery is being increasingly used for many colorectal diseases.

Laparoscopic colectomy is an underused procedure for the treatment of colovesical fistulas despite the fact that this technique is associated with better outcomes including lower mortality, lower complication rate, and shorter length of stay when compared with OC.

REFERENCES

1. Zapletal C, Woeste G, Bechstein W, et al. Laparoscopic sigmoid resections for diverticulitis complicated by abscesses or fistulas. Int J Colorectal Dis 2007;22:1515-21.

2. Vaid S, Tucker J, Bell T, et al. Cost analysis of laparoscopic versus open colectomy in patients with colon cancer: Results form a large nationwide population database. Am Surg 2012;78: 635-41.

3. Kwon S, Billingham R, Farrokhi E, et al. Adoption of laparoscopic for elective colorectal resection: a report from the Surgical Care and Outcomes Assessment Program. J Am Coll Surg 2012;214:909-18.

4. Simorov A, Shaligram A, Shostrom V, et al. Laparoscopic colon resection trends in utilization and rate of conversion to open procedure. Ann Surg 2012;256:462-8.

Abstract presented in the meeting of the American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 29, 2013.

Address correspondence and reprint requests to Haisar E. Dao, M.D., 2 Dudley Street, Suite 370, Providence, RI 02903. E-mail: [email protected].

Haisar E. Dao, M.D.

Department of Colorectal Surgery

Warren Alpert Medical School

Brown University

Providence, Rhode Island

Peter E. Miller, M.D.

Department of Surgery

Tufts University School of Medicine

Steward St. Elizabeth's Medical Center

Boston, Massachusetts

Satyadeep Bhattacharya, M.D.

Adam Klipfel, M.D.

Department of Colorectal Surgery

Warren Alpert Medical School

Brown University

Providence, Rhode Island

Matthew Vrees, M.D.

Steven Schechter, M.D.

Department of Surgery

Warren Alpert Medical School

Brown University

Providence, Rhode Island