ORIGINAL ARTICLE

Comparing incidence of enterocolitis after laparoscopic andopen low anterior resection for stage II/III rectal cancerMasafumi Inomata,1 Toru Kusano,1 Tsuyoshi Etoh,1 Tomonori Akagi,1 Tomotaka Shibata,1 Yoshitake Ueda,2

Manabu Tojigamori,1 Hidefumi Shiroshita,1 Tsuyoshi Noguchi,2 Norio Shiraishi2 & Seigo Kitano3

1 Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan

2 Center for Community Medicine, Oita University Faculty of Medicine, Oita, Japan

3 Oita University, Oita, Japan

KeywordsEnterocolitis; laparoscopic surgery; rectal

cancer

CorrespondenceMasafumi Inomata, Department of

Gastroenterological and Pediatric Surgery,

Oita University Faculty of Medicine, 1-1

Hasama-machi, Yufu, Oita 879-5593, Japan.

Tel: +81 97 586 5843

Fax: +81 97 549 6039

Email: inomata@oita-u.ac.jp

Received: 28 November 2013; revised 4

February 2014; accepted 2 March 2014

DOI:10.1111/ases.12100

Abstract

Introduction: We recently observed an increased incidence of severeenterocolitis following laparoscopic low anterior resection (LAR) in somepatients with stage II/III rectal cancer. This study aimed to examine theinfluence of laparoscopic LAR on postoperative enterocolitis compared withopen LAR for Stage II/III rectal cancer.Methods: From April 2002 to March 2012, we evaluated 65 patients with stageII/III cancer of the upper or lower rectum who underwent LAR. Among these,27 patients underwent open LAR and 38 underwent laparoscopic LAR. First,we compared short-term outcomes between the two groups. Next, we evalu-ated the incidence of postoperative enterocolitis in the laparoscopic LARgroup. The clinicopathological factors were examined by univariate and oddsratio (OR) analysis.Results: Univariate analysis revealed significant differences in the occupancyrate, tumor location, depth of tumor invasion, operative time, amount ofintraoperative blood loss, and postoperative enterocolitis between the laparo-scopic and open groups. Postoperative enterocolitis developed in 6 of 38patients (15.8%) in the laparoscopic group and in no patient in the opengroup. The occurrence of postoperative enterocolitis was significantly associ-ated with BMI (≥28 kg/m2), operative time, and wound infection in thelaparoscopic LAR group (OR: 0.11, 95% confidence interval: 0.044–0.280,P < 0.05; OR: 1.40, 95% confidence interval: 1.068–1.835, P < 0.05; and OR:15.0, 95% confidence interval, 1.752–128.310, P < 0.05, respectively).Conclusion: Postoperative enterocolitis occurred more frequently after laparo-scopic LAR than after open LAR in patients with stage II/III rectal cancer.Clinical management in the perioperative period of laparoscopic LAR is nec-essary to prevent postoperative enterocolitis in obese patients and those witha prolonged operative time.

Introduction

The use of laparoscopic surgery for colorectal cancer hasbecome widespread because of its minimal invasiveness.According to the 11th Nationwide Survey of EndoscopicSurgery performed by the Japan Society for EndoscopicSurgery, 16 417 patients with colorectal cancer under-went laparoscopic surgery in 2011 (1). Laparoscopic

surgery for colon cancer is recognized as a standardtherapeutic modality, and the indications of this proce-dure for rectal cancer have been gradually expanded.

Some studies have reported no significant differencesin short-term and long-term outcomes between laparo-scopic and open surgery for colon cancer (2–5). Withregard to rectal cancer, some studies have reported thatthe complication rate after laparoscopic surgery is similar

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to that after open surgery and that there is no compro-mise in oncological outcomes with the former (6–8).However, the complication rate with laparoscopicsurgery is reportedly higher for rectal cancer than forcolon cancer (9). According to a report by McKay et al.,the anastomotic leakage rate after laparoscopic surgeryfor rectal and colon cancer was 5.1% and 1.2%, respec-tively, while the intra-abdominal abscess rate was 6.4%and 0.9%, respectively (9). Additionally, Yamamoto et al.also reported that the anastomotic leakage rate inpatients with stage 0/I rectal cancer who underwentlaparoscopic anterior resection was 8.3% (10).

We recently observed the development of severeenterocolitis in some patients who underwent laparo-scopic low anterior resection (LAR) for stage II/III rectalcancer. However, the frequency of postoperativeenterocolitis is not mentioned in the 11th NationwideSurvey of Endoscopic Surgery performed by the JapaneseSociety for Endoscopic Surgery. In addition, no reportson severe enterocolitis in patients who have undergonelaparoscopic LAR for rectal cancer are available. Wereported the development of transient liver dysfunctionin patients who underwent laparoscopic gastrectomyunder CO2 pneumoperitoneum, and three patients whounderwent laparoscopic gastrectomy among a cohort of27 patients with liver disease suffered severe enteritis(11). It has been hypothesized that mesenteric hypoxiaand related gut ischemia–reperfusion injury, which occurduring and after pneumoperitoneum, pose a significantclinical problem (12). However, only a few clinicalreports of oxidative stress from laparoscopic surgery exist(11,13).

In this study, we examined the rate of postoperativeischemia-related complications, including enterocolitisafter laparoscopic LAR, and compared it with the rateafter open LAR in patients with stage II/III rectal cancer.In addition, we examined whether laparoscopic LARinfluences the development of postoperative enterocolitisin patients with stage II/III rectal cancer.

Materials and Methods

From April 2002 to March 2012, 252 patients with rectalcancer underwent initial surgery at the Department ofGastroenterological and Pediatric Surgery, Oita Univer-sity Faculty of Medicine (Oita, Japan). We excludedpatients with distant metastasis and those who under-went abdominoperineal resection because of the absenceof anastomosis. In Japan, D3 lymphadenectomy isdefined as the dissection of the inferior mesenteric arterylymph nodes and lateral pelvic lymph nodes. We alsoexcluded patients with preoperatively diagnosed lateralpelvic lymph node enlargement because they required

lateral pelvic lymph node dissection. Therefore, weselected 65 patients with stage II/III cancer of the upperor lower rectum who required LAR with total mesorectalexcision or tumor-specific mesorectal excision with infe-rior mesenteric artery lymph node dissection. Cancerstage was assessed according to the seventh edition of theUICC-TNM Classification of Malignant Tumors.

In our institution, we have been performing laparo-scopic LAR for advanced rectal cancer since 2007. There-fore, in this study, open LAR was performed for advancedrectal cancer from 2002 to 2006. For advanced rectalcancer with invasion to other organs (T4b), we haveperformed open LAR since 2007. During the procedure,pneumoperitoneum was induced and maintained under10-mmHg CO2. The left colic artery was preserved duringboth laparoscopic and open LAR. Anastomosis wasachieved by the double stapling technique or hand-sewnwhen the patient required super-LAR. We also intro-duced a clinical pathway during surgery for colorectalcancer at our institution: protocol, patients werepreoperatively prepared according to the Guideline forPrevention of Surgical Site Infection, 1999 (14). Allpatients were asked to take polyethylene glycol,neomycin, and erythromycin on the day before surgery.Cefmetazole, an antibiotic, was administered on the dayof surgery.

In this study, six patients were treated by preoperativechemoradiotherapy (CRT). Preoperative CRT wasselected according to several preoperative sequentialtreatment protocols developed at our institute between2001 and 2012. This involved the TS-1 chemotherapyregimen, which includes tegafur, gimeracil, and oteracilpotassium (80 mg/m2/day), and five fractions of radio-therapy (45 Gy at the rate of 1.8 Gy/day) every week.Our criteria for preoperative CRT was advanced rectalcancer pathologically diagnosed as adenocarcinoma andpreoperatively diagnosed as T3/T4, N0-3 cancer. Primarytumor and nodal staging before and after CRT was per-formed using pelvic MRI and CT. Lymph nodes measur-ing 10 mm in diameter were considered to be metastases.If metastatic lateral pelvic lymph nodes could not bedetected, lateral pelvic lymph node dissection was notperformed. After surgery, the patients were examined atfollow-up visits conducted every 3 months for the first 2years and every 6 months thereafter.

At each follow-up visit, carcinoembryonic antigen andCA19-9 levels were determined. Thoracoabdominal andpelvic CT or abdominal ultrasonography was performedalternately every 3–6 months. Colonoscopy was per-formed annually.

We first divided the patients into two groups accordingto surgical procedure: the open group (n = 27) and thelaparoscopic group (n = 38). Age and sex of the patients,

Severe enterocolitis after lap LAR M Inomata et al.

Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd2

tumor location, tumor size, histological type, depth oftumor invasion, extent of lymphatic and vascular tumorinvasion, number of positive lymph nodes, operativetime, and amount of intraoperative blood loss werereviewed from the patients’ surgical and pathologicalrecords. These clinicopathological characteristics and theshort-term outcomes of LAR were compared between theopen and laparoscopic groups. The pathological charac-teristics of patients in the open and laparoscopic groupswere compared using the Fisher’s exact test or Mann–Whitney U-test.

Next, we focused on the incidence of enterocolitisafter surgery. Postoperative enterocolitis was definedusing the Common Terminology Criteria for AdverseEvents version 4.0. Because severe enterocolitisoccurred only after laparoscopic LAR, patients weredivided into two groups according to the absence(n = 32) or presence (n = 6) of this complication (grade3 or higher). Similarly, the pathological characteristicsof patients in these two groups were compared usingthe Fisher’s exact test or Mann–Whitney U-test. TheWilcoxon rank test was used to compare median age,size of tumor, operative time, amount of intraoperativeblood loss, and postoperative hospitalization durationamong groups. Variables with P-values less than 0.05 inunivariate analysis were included in odds ratios andcorresponding 95% confidence intervals (CI). A P-valuegreater than 0.05 was considered statistically significantfor all analyses.

All statistical analyses were performed using the SPSS11.0 statistical software program for Windows (SPSS Inc.,Chicago, USA). This study was conducted according tothe Ethical Guidelines for Clinical Studies of Oita Univer-sity Faculty of Medicine.

Results

In this study, all 65 patients with stage II/III rectal cancerunderwent curative LAR. Univariate analysis revealedthat the occupancy rate, tumor location, and depth oftumor invasion were significantly different between theopen and laparoscopic LAR groups (P < 0.05) (Table 1).In addition, there were significant differences in theoperative time, amount of intraoperative blood loss, andincidence of enterocolitis between the open and laparo-scopic LAR groups (P < 0.05) (Table 2). Postoperativeenterocolitis occurred in six patients (five men, onewoman; median age, 74.5 years; interquartile range[IQR], 61.2–78.7 years; mean BMI, 26.3 ± 8.09 kg/m2) inthe laparoscopic LAR group. The clinicopathological fea-tures and short-term outcomes of the six patients withpostoperative enterocolitis are shown in Table 3. Themedian onset period of enterocolitis was 3 days after

surgery, and all six patients developed grade 3 postopera-tive enterocolitis. The median operative time and amountof intra-operative blood loss of patients with postopera-tive enterocolitis were 405 min (IQR, 362.7–470.7 min)and 185 mL (IQR, 142.5–205.0 mL), respectively. Themedian tumor size was 44 cm (IQR, 39.0–61.7 cm) andthe median length of hospitalization was 27 days (IQR,23.5–71.0 days). The incidence of wound infection was50% (3/6). Regarding clinical data such as fever, whiteblood cell count, and C-reactive protein (CRP), themedian fever was 38.8°C (IQR, 38.3–39.2°C). Themedian white blood cell count was 7945/mm3 (IQR,6572–9040/mm3) and the median C-reactive protein was15.6 mg/L (IQR, 13.4–23.1 mg/L).

In the laparoscopic group, there were significant dif-ferences in BMI (≥28 kg/m2), operative time, postopera-

Table 1 Clinicopathological features of patients who underwent lowanterior resection for stage II/III rectal cancer

Patient demography

Open

(n = 27)

Laparoscopy

(n = 38) P-value

Sex (n) 0.918

Male 16 (59.3%) 23 (60.5%)

Female 11 (40.7%) 15 (39.5%)

Age (years) 0.370

Median 67 64.5

Range 26–85 32–82

BMI (kg/m2) 0.190

<28 23 (85.2%) 36 (94.7%)

≥28 4 (14.8%) 2 (5.3%)

Size of tumor (mm) 0.344

Median 55 45.5

Range 30–120 20–90

Circumferential occupying

rate (n)

<50% 1 (3.7%) 14 (36.8%) 0.002

≥50% 26 (96.3%) 24 (63.2%)

Preoperative CRT (n)

Performed 1 (3.7%) 5 (13.2%) 0.412

Not performed 26 (96.3%) 33 (86.8%)

Location (n)

Upper 22 (81.5%) 20 (52.6%) 0.017

Lower 5 (18.5%) 18 (47.4%)

T (n)

T3 16 (59.3%) 34 (89.5%) <0.01

T4 11 (40.7%) 4 (10.5%)

N (n)

N0 10 (37.0%) 19 (50.0%) 0.633

N1 11 (40.7%) 10 (26.3%)

N2 5 (18.5%) 8 (21.1%)

N3 1 (3.7%) 1 (2.6%)

Stage (n)

Stage II 10 (37.0%) 19 (50.0%) 0.544

Stage III A 10 (37.0%) 10 (26.3%)

Stage III B 7 (26.0%) 9 (23.7%)

CRT, chemoradiation therapy.

M Inomata et al. Severe enterocolitis after lap LAR

Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd 3

tive hospitalization, and incidence of wound infectionbetween the absence of postoperative enterocolitis andpresence of postoperative enterocolitis groups (P < 0.05)(Table 4). Regarding subanalysis of the laparoscopic LARgroup, cases with an operative time of more than330 min were associated with occurrence of postopera-tive enterocolitis (P ≤ 0.05).

Subsequent odds ratio analysis using factors significantin univariate analysis revealed that BMI (≥ 28 kg/m2),operative time, and incidence of wound infection were0.111 (95%CI, 0.044–0.280, P ≤ 0.05), 1.40 (95%CI,1.068–1.835, P ≤ 0.05), and 15.0 (95%CI, 1.752–128.310, P ≤ 0.05), respectively (Table 5).

Discussion

In this study, laparoscopic surgery for rectal cancer wasassociated with a less intraoperative blood loss than opensurgery, and the operative time in the laparoscopic groupwas longer than in the open group. These results areconsistent with those of other reports (15,16). The inci-dence of postoperative enterocolitis in the laparoscopicgroup was higher than in the open group. The occur-rence of enterocolitis after laparoscopic LAR was associ-ated with BMI (≥28 kg/m2), operative time, and woundinfection. In this study, although only 15% (6/38) ofpatients who underwent laparoscopic LAR went on todevelop enterocolitis, these patients developed severeenterocolitis of grade 3 or higher (Common TerminologyCriteria for Adverse Events version 4.0). This suggeststhat clinical management for postoperative enterocolitisis necessary in patients who undergo laparoscopic LARfor advanced rectal cancer.

Recently, Yamamoto et al. reported that laparoscopicsurgery can be used for safe resection of clinical stage 0/Irectal carcinoma (10). According to their report, the rateof postoperative enterocolitis was 0.25% (1/400). Evi-dence indicates that postoperative enterocolitis is a rarecomplication. For stage 0/I, which was excluded fromthis study, the rate of enterocolitis after open and lapa-roscopic LAR was 6.6% (1/15) and 2.9% (1/34), respec-tively (data not shown). There was no significantdifference in the incidence of postoperative enterocolitisbetween the open and laparoscopic groups with stage 0/Irectal cancer. Interestingly, only patients who underwentlaparoscopic LAR for advanced rectal cancer went on todevelop enterocolitis in the present study. We thereforebelieve that the incidence of postoperative enterocolitismay be associated with laparoscopic procedures forpatients with advanced rectal cancer.

Some studies have examined the surgical risk factorsfor enterocolitis. Evasovich et al. reported that CO2

pneumoperitoneum increased the incidence ofEscherichia coli bacterial translocation in a rat model (17).In clinical settings, there have been some reports ofmesenteric ischemia, reduction of portal venous flow,and bowel infarction after laparoscopic surgery (18–22).During laparoscopic LAR for rectal cancer in the presentstudy, patients were maintained in the Lloyd–Daviesposition. Therefore, we hypothesize that the intestinebecomes congested by the decrease in portal venous flowsubsequent to a rise in portal pressure and the intestinebecomes susceptible to a mucosal membrane disorder.Furthermore, we hypothesize that enterocolitis is associ-ated with prolonged pneumoperitoneum subsequent toprolonged operative time. As a result, subanalysisrevealed that the cases with an operative time greater

Table 2 Short-term outcomes of patients who underwent low anteriorresection for stage II/III rectal cancer

Open

(n = 27)

Laparoscopy

(n = 38) P-value

Operative findings

Operation

Operative time (min)

Median 265 352 0.01

Range 155–570 211–1340

Intraoperative blood loss

(mL)

Median 360 155 0.015

Range 30–2800 5–2000

Intraoperative blood

transfusion (n)

Performed 6 (22.2%) 3 (7.9%) 0.099

Not performed 21 (77.8%) 35 (92.1%)

Anastomotic method (n)

Stapled 25 (92.6%) 33 (86.8%) 0.461

Hand-sewn 2 (7.4%) 5 (13.2%)

Short-term outcomes

Postoperative course

Length of hospitalization

(day)

Median 18 17 0.354

Range 11–58 9–92

Operative complications

(n)

Present 6 (22.2%) 7 (18.4%)

Leakage 0 2 0.22

Intra-abdominal

abscess

1 4 0.31

Ileus 2 0 0.089

Wound infection 3 5 0.80

Neurogenic bladder 4 1 0.07

Enterocolitis 0 6 0.03

Absent 21 (77.8%) 31 (81.6%)

30-days mortality (n)

Present 0 (0%) 0 (0%) 0.99

Absent 27 (100%) 38 (100%)

CRT, chemoradiation therapy.

Severe enterocolitis after lap LAR M Inomata et al.

Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd4

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M Inomata et al. Severe enterocolitis after lap LAR

Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd 5

Table 4 Clinicopathological features and short-term outcomes of patients after laparoscopic low anterior resection for stage II/III rectal cancer with/without postoperative enterocolitis

Enterocolitis

P-valueAbsent (n = 32) Present (n = 6)

Patient demographySex (n) 0.219

Male 18 (56.3%) 5 (83.3%)Female 14 (43.8%) 1 (16.7%)

Age (years) 0.279Median 64 74.5Range 32–82 49–82

BMI (kg/m2) 0.021<28 32 (100%) 4 (66.7%)≥28 0 (0%) 2 (33.3%)

Size of tumor (mm) 0.384Median 47.5 44Range 20–90 35–90

Circumferential occupying rate (n) 0.401<50% 27 (84.4%) 2 (33.3%)≥50% 5 (15.6%) 4 (66.7%)Preoperative CRT (n) 0.412

Performed 5 (15.6%) 0 (0%)Not performed 27 (84.4%) 6 (100%)

Location (n) 0.069Upper 19 (59.4%) 1 (16.7%)Lower 13 (40.6%) 5 (83.3%)

T (n)T3 28 (87.5%) 6 (100%) 0.487T4 4 (12.5%) 0 (0%)

N (n)N0 17 (53.1%) 2 (33.3%) 0.241N1 8 (25.0%) 2 (33.3%)N2 7 (21.9%) 1 (16.7%)N3 0 (0%) 1 (16.7%)

Stage (n)Stage II 17 (53.1%) 2 (33.3%) 0.816Stage IIIA 10 (31.3%) 2 (33.3%)Stage IIIB 5 (15.6%) 2 (33.3%)

Operative findingsOperation

Operative time (min) 0.020Median 332.5 405.5Range 210–730 336–1340

Intraoperative blood loss (mL) 0.571Median 125 185Range 5–560 100–2000

Intraoperative blood transfusion (n) 0.412Performed 30 (93.8%) 1 (16.7%)Not performed 2 (6.3%) 5 (83.3%)

Anastomotic method (n)Stapled 29 (90.6%) 4 (66.7%) 0.169Hand-sewn 3 (9.4%) 2 (33.3%)

Short-term outcomesPostoperative course

Length of postoperative hospitalization (day) 0.005Median 15.5 27Range 9–67 14–92

Operative complication (n)Present 4 (12.5%) 3 (50.0%)

Leakage 2 0 0.65Intra-abdominal abscess 3 1 0.39Ileus 0 0 0.75Wound infection 2 3 0.003Neurogenic bladder 0 0 0.75

Absent 28 (87.5%) 3 (50.0%)

CRT, chemoradiation therapy.

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Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd6

than 330 min were associated with the occurrence ofpostoperative enterocolitis (P ≤ 0.05).

There may be several factors underlying the develop-ment of enterocolitis. Although enterocolitis is related toantibiotic-associated diarrhea or radiation, no significantdifferences were noted them between the open and lapa-roscopic groups in this study. Therefore, we investigatedthe possibility that postoperative enterocolitis developedbecause of a mucosal membrane disorder or mesentericischemia following prolonged pneumoperitoneum. It isknown that 60%–70% of immune cells that control sys-temic immunity exist in the intestine and not in thelymph nodes and spleen (23–25). The gut-associatedlymphoid tissue comprises immune cells in Peyer’spatches in the intestine, and this tissue controls intestinalimmunity (26–28). Because of mesenteric hypoxia andrelated gut ischemia–reperfusion injury that occursduring and after pneumoperitoneum, the intestine canbecome extremely susceptible to a mucosal membranedisorder, which is a risk factor for postoperative bacterialtranslocation. In such a setting, severe enterocolitis maybe caused by either the excessive immune response orfailure of the body’s protection system. It makes sensethat there was a significant difference in the incidence ofwound infection between the absence of postoperativeenterocolitis and presence of postoperative enterocolitisgroups.

We generally perform laparoscopic LAR withpneumoperitoneum at 10 mmHg because pneumoperi-toneum at 12–15 mmHg increases the intra-abdominalpressure above the normal portal circulation pressure(29). It has been reported that pneumoperitoneum pres-sure at 10–15 mmHg significantly decreased blood flowin the stomach by 40%, jejunum by 32%, liver by 39%,and colon by 44% (30). Because this study is a retrospec-tive study, blood flow in the splanchnic vessels could notbe measured. Therefore, it is necessary to examine therelationship between blood flow in the splanchnic vesselsand the incidence of postoperative enterocolitis in thefuture.

It has been reported that the Lloyd–Davies positionconstitutes a risk factor for acute lower limb compart-ment syndrome, but the incidence of lower limb andabdominal compartment syndrome following laparo-scopic colorectal surgery remains unknown (31). In con-trast, the same report suggested that decreased venousreturn with pooling in the mesentery resulted fromincreased intra-abdominal pressure during laparoscopicsurgery in the Lloyd–Davies position (31). Now, based onthe results of this study, we try to return patients to theflat position from the Lloyd–Davies position and degasthe abdomen every 2 h. Since we initiated these mea-sures, we have not experienced a single case of postop-erative enterocolitis. In the future, to elucidate themechanisms by which postoperative enterocolitis occurs,operative time, position, and monitoring of relativeperfusion will be needed. However, the number of casesof severe postoperative enterocolitis is small within asingle institution, and multivariate analysis may not beavailable for such a study. For this reason, it will benecessary to examine severe enterocolitis after laparo-scopic surgery in a multicenter study.

In conclusion, we demonstrated that the incidence ofpostoperative enterocolitis was higher after laparoscopicsurgery than after open surgery for stage II/III rectalcancer. Clinical management in the perioperative periodof laparoscopic LAR is necessary to prevent postoperativeenterocolitis in obese patients and those with a prolongedoperative time.

Acknowledgments

The authors have no conflicts of interest or financial tiesto disclose.

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Table 5 Odds ratio of incidence of enterocolitis after laparoscopic low anterior resection

Enterocolitis

Odds ratio (95%CI) P-valueAbsent (n = 32) Present (n = 6)

BMI (kg/m2) 0.021

<28 32 (100%) 4 (66.7%) 0.111 (0.044–0.280)

≥28 0 (0%) 2 (33.3%)

Operative time (min) 0.020

Median 332.5 405.5 1.40 (1.068–1.835)

Range 210–730 336–1340

Wound infection (n) 2 (6.3%) 3 (50.0%) 15.0 (1.752–128.310) 0.003

CI, confidence interval.

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Asian J Endosc Surg •• (2014) ••–••© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd 7

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