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Cariati M, Brisinda G, Chiarello MM. Has the open surgical approach in colorectal cancer really become uncommon? World J Gastrointest Surg 2024; 16:1485-1492. [PMID: 38983350 PMCID: PMC11230011 DOI: 10.4240/wjgs.v16.i6.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 06/27/2024] Open
Abstract
Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Giuseppe Brisinda
- Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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Troller R, Bawa J, Baker O, Ashcroft J. First experience in laparoscopic surgery in low and middle income countries: A systematic review. World J Gastrointest Surg 2024; 16:546-553. [PMID: 38463379 PMCID: PMC10921192 DOI: 10.4240/wjgs.v16.i2.546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Laparoscopic surgery has reduced morbidity and mortality rates, shorter postoperative recovery periods and lower complication rates than open surgery. It is routine practice in high-income countries and is becoming increasingly common in countries with limited resources. However, introducing laparoscopic surgery in low-and-middle-income countries (LMIC) can be expensive and requires resources, equipment, and trainers. AIM To report the challenges and benefits of introducing laparoscopic surgery in LMIC as well as to identify solutions to these challenges for countries with limited finances and resources. METHODS MEDLINE, EMBASE and Cochrane databases were searched for studies reporting first experience in laparoscopic surgery in LMIC. Included studies were published between 1996 and 2022 with full text available in English. Exclusion criteria were studies considering only open surgery, ear, nose, and throat, endoscopy, arthroscopy, hysteroscopy, cystoscopy, transplant, or bariatric surgery. RESULTS Ten studies out of 3409 screened papers, from eight LMIC were eligible for inclusion in the final analysis, totaling 2497 patients. Most reported challenges were related to costs of equipment and training programmes, equipment problems such as faulty equipment, and access to surgical kits. Training-related challenges were reliance on foreign trainers and lack of locally trained surgeons and theatre staff. The benefits of introducing laparoscopic surgery were economic and clinical, including a reduction in hospital stay, complications, and morbidity/mortality. The introduction of laparoscopic surgery also provided training opportunities for junior doctors. CONCLUSION Despite financial and technical challenges, many studies emphasise the overall benefit of introducing laparoscopic surgery in LMICs such as reduced hospital stay and the related lower cost for patients. While many of the clinical centres in LMICs have proposed practical solutions to the challenges reported, more support is critically required, in particular regarding training.
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Affiliation(s)
- Rebekka Troller
- Department of Surgery, Medway Maritime Hospital, Gillingham ME7 5NY, Kent, United Kingdom
| | - Jasmine Bawa
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Olivia Baker
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - James Ashcroft
- Department of Surgery, University Hospital Cambridge, Cambridge CB2 0QQ, United Kingdom
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3
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Pathak A, Wanjari M. Minimally Invasive Colorectal Surgery Techniques. Cureus 2023; 15:e47203. [PMID: 38021760 PMCID: PMC10652800 DOI: 10.7759/cureus.47203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Colorectal surgery has witnessed a transformative shift with the advent of minimally invasive techniques, offering patients reduced postoperative discomfort, shorter hospital stays, and accelerated recovery compared to conventional open surgery. This comprehensive review aims to assess the current state of minimally invasive approaches in colorectal surgery, encompassing various techniques such as single-incision laparoscopic surgery, robot-assisted surgery, and conventional laparoscopic surgery. The article meticulously explores the benefits and drawbacks of each technique, delves into the established criteria for their application, delineates cautious circumstances, and analyzes the outcomes of minimally invasive colorectal surgery. Additionally, the integration of virtual reality and augmented reality for surgical planning and training is discussed, shedding light on the future trajectory of this field. Surgeons and researchers striving to enhance patient care and surgical outcomes in colorectal surgery will find this review article an invaluable resource, presenting crucial components of minimally invasive colorectal surgery and paving the way for continued advancements in the field.
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Affiliation(s)
- Akash Pathak
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mayur Wanjari
- Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Bakula B. Is non-mentored initiation of laparoscopic colorectal surgery safe? Single surgeon initial experience with the first 40 cases. Front Surg 2023; 10:1196037. [PMID: 37744727 PMCID: PMC10512303 DOI: 10.3389/fsurg.2023.1196037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Although laparoscopic colorectal surgery is now accepted as a standard procedure in treating colorectal cancer, the proportion of laparoscopically operated patients with colorectal cancer is still generally quite low. The aim of this study is to assess feasibility, safety, and outcomes of a non-mentored initiation of laparoscopic colorectal resections by a young surgeon without previous experience in laparoscopic colorectal surgery. Materials and methods We analyzed the characteristics of the first 40 elective cases of laparoscopic colorectal resections performed by a single surgeon during the period between June 2019 and March 2022. All of the operations were performed without the attendance or supervision of an experienced surgeon in laparoscopic colorectal surgery. The patients were divided into three groups (the early, intermediate, and late group). Results The conversion rate, complications rate, and postoperative recovery were similar among groups. The mean overall operative time was 219.5 min (range 130-420 min) and had reduced significantly during the learning curve (p = 0.047). The overall conversion rate was 12.5%. In two cases (5%), the oncological principles were violated (incomplete total mesorectal excision). In three patients (7.5%), intraoperative complications had occurred (small bowel injury, splenic injury, and significant bleeding from the minor peripancreatic artery). Three cases of major postoperative complications (Clavien-Dindo grade III) were recorded, two of which required reoperation (anastomotic bleeding and fascial dehiscence). There was no 90-day mortality reported. The overall mean number of lymph nodes retrieved was 12.45, which did not differ significantly among groups (p = 0.678). The average follow-up was 13.75 months (range 1-31 months). Cancer recurrence was recorded in four patients (10%). Port-site metastasis was not detected in any of the cases. Conclusion A safe and non-mentored initiation of laparoscopic colorectal surgery with an acceptable rate of complications and acceptable oncological results can be achieved. Still, when compared with a structured initiation in a controlled environment with the supervision of an experienced surgeon in laparoscopic colorectal surgery, the results of a non-mentored initiation are worse in most of the fields, including operative time, conversion rate, complications rate, and duration of hospital stay. Therefore, I strongly recommend engaging young surgeons in fellowship programs on structured laparoscopic colorectal surgery whenever possible before starting performing these procedures on their own.
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Affiliation(s)
- Branko Bakula
- Department of Surgery, University Hospital Sveti Duh, Zagreb, Croatia
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Janssen ERC, Punt IM, Biemans CFM, van Rhijn L, Willems PC, van Meeteren NLU. Preoperative community based functional high intensity interval training ( f-HIIT) with high-risk patients opting for lumbar spinal fusion: a pilot study. Disabil Rehabil 2023; 45:805-813. [PMID: 35195480 DOI: 10.1080/09638288.2022.2040618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the feasibility, safety and preliminary effectiveness of preoperative functional high-intensity interval training (f-HIIT) for high-risk patients undergoing LSF. MATERIALS AND METHODS High-risk patients eligible for elective 1-3 level LSF were included. Feasibility and safety of the preoperative f-HIIT program was determined by measuring participation and attrition rates, training adherence, adverse events, reached training intensity and preoperative progression in physical fitness. Preliminary effect of the preoperative f-HIIT program was estimated on time to postoperative functional recovery and length of hospital stay (LoS) between high-risk patients who did and did not participate in the prehabilitation program. RESULTS Eleven out of 23 high-risk patients opted to participate in the f-HIIT program, which was safe and feasible, as no adverse events occurred and only one out of 74 sessions was missed (1.4%). Trained high-risk patients improved their physical fitness with 21.2% on average and obtained faster time to functional recovery compared to matched untrained patients (median 4.5 vs 7.5 days; p = 0.013). No effect was seen on LoS (median 7 vs 8 days (p = 0.58)). CONCLUSIONS The preoperative f-HIIT program is feasible, safe and shortened time to postoperative functional recovery in patients who underwent LSF.Implications for rehabilitationPreoperative high-intensity interval training is safe and feasible for high-risk patients opting for lumbar spinal fusion.In a relatively small sample the study shows preoperative high-intensity interval training could reduce time to functional recovery in high-risk patients opting for lumbar spinal fusion.
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Affiliation(s)
- Esther R C Janssen
- Department of Orthopedics and Research School Caphri, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Orthopedic Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Ilona M Punt
- Department of Orthopedics and Research School Caphri, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Department of Surgery and Trauma Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Camille F M Biemans
- Department of Orthopedics and Research School Caphri, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Lodewijk van Rhijn
- Department of Orthopedics and Research School Caphri, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Paul C Willems
- Department of Orthopedics and Research School Caphri, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health ∼ Holland), The Hague, the Netherlands
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
- Topcare, Leiden, the Netherlands
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Ebrahimian S, Verma A, Sakowitz S, Olmedo MO, Chervu N, Khan A, Hawkins A, Benharash P, Lee H. Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis. PLoS One 2023; 18:e0284729. [PMID: 37115767 PMCID: PMC10146460 DOI: 10.1371/journal.pone.0284729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease. METHODS All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest. RESULTS Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436). CONCLUSION In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.
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Affiliation(s)
- Shayan Ebrahimian
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Arjun Verma
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Manuel Orellana Olmedo
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Nikhil Chervu
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Aimal Khan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Alexander Hawkins
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Peyman Benharash
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, United States of America
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Lee S. The impact of assistants' reverse alignment surgical skill proficiency on laparoscopic colorectal surgery. Ann Coloproctol 2022; 38:432-441. [PMID: 35045685 PMCID: PMC9816554 DOI: 10.3393/ac.2021.00689.0098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/12/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE We aimed to investigate the difference in the surgical outcome based on whether the assistant overcame the mirror image in laparoscopic colorectal surgery. METHODS Three hundred patients who underwent laparoscopic colorectal surgery performed by single operator were divided into 2 groups. Based on the assistants' experience, patients who underwent surgery involving 1 of 6 residents with an experience of fewer than 30 surgeries each were classified into group 1. Patients who underwent surgery involving a single fellow as an assistant with an experience of over 1,000 surgeries were classified into group 2. According to the type of surgery, patients were divided into left and right colon resection groups and the surgical outcome of groups 1 and 2 was investigated. RESULTS Group 2 exhibited shorter operation time, less bleeding, shorter postoperative hospital stay, lower open conversion, and anastomotic leakage rate than group 1. In right colon resection, the operation time was shorter in group 2. In left colon resection, group 2 exhibited shorter operation time, less bleeding, shorter postoperative hospital stay, and lower anastomotic leakage rate. In the multivariate analysis, the assistant was a factor affecting the operation time in the entire surgery. CONCLUSION Assistants' reverse alignment surgical skill proficiency was a factor affecting the operation time.
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Affiliation(s)
- Seunghun Lee
- Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea,Correspondence to: Seunghun Lee, M.D., Ph.D. Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea Tel: +82-51-990-6181, Fax: +82-51-246-6093 E-mail:
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Jang JH. Can assistants' skills be used to improve colorectal cancer surgery outcomes in a way similar to the "butterfly effect"? Ann Coloproctol 2022; 38:391-392. [PMID: 36596298 PMCID: PMC9816555 DOI: 10.3393/ac.2022.01088.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022] Open
Affiliation(s)
- Je-Ho Jang
- Department of Surgery, Eulji University School of Medicine, Daejeon, Korea,Correspondence to: Je-Ho Jang, M.D. Department of Surgery, Daejeon Eulji University Hospital, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: +82-42-259-1335, Fax: +82-42-259-1335 E-mail: ORCID: https://orcid.org/0000-0001-8935-6449
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Vanella S, Bottazzi EC, Farese G, Murano R, Noviello A, Palma T, Godas M, Crafa F. Minimally invasive colorectal surgery learning curve. World J Gastrointest Endosc 2022; 14:731-736. [PMID: 36438877 PMCID: PMC9693684 DOI: 10.4253/wjge.v14.i11.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2022] Open
Abstract
The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.
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Affiliation(s)
- Serafino Vanella
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Enrico Coppola Bottazzi
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Giancarlo Farese
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Rosa Murano
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Adele Noviello
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Tommaso Palma
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Maria Godas
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Francesco Crafa
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
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Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis. Cancers (Basel) 2022; 14:cancers14205089. [PMID: 36291872 PMCID: PMC9600114 DOI: 10.3390/cancers14205089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary Rectal cancer surgery remains a challenge and information about the learning curve in adopting new techniques is lacking. This paper analyzes our experience in taTME (since 2015) and robotic surgery (since 2018) at a fully accredited referral center for the treatment of rectal cancer in Spain. In this retrospective study, we aim to analyze the learning curves for taTME and robot-assisted rectal procedures in the incorporation of these platforms into our practice. We sought to describe our team’s experience in incorporating these techniques and to analyze the difficulties that we have had. Hoping that sharing our experience can help other groups improve their results during the difficult initial phase of incorporating new techniques. Abstract New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.
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Bayat Z, Guidolin K, Elsolh B, De Castro C, Kennedy E, Govindarajan A. Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review. BJS Open 2022; 6:6704875. [PMID: 36124901 PMCID: PMC9487584 DOI: 10.1093/bjsopen/zrac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS. Methods A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration. Results A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS. Conclusion Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.
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Affiliation(s)
- Zubair Bayat
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Keegan Guidolin
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | - Basheer Elsolh
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | | | - Erin Kennedy
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Anand Govindarajan
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
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Angeramo CA, Schlottmann F, Laporte M, Bun ME, Rotholtz NA. Re-laparoscopy to Treat Early Complications After Colorectal Surgery: Is There a Learning Curve? Surg Laparosc Endosc Percutan Tech 2022; 32:362-367. [PMID: 35583576 DOI: 10.1097/sle.0000000000001052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Laparoscopy for treating complications after laparoscopic colorectal surgery (LCS) is still controversial. Moreover, its learning curve has not been evaluated yet. The aim of this study was to analyze whether operative outcomes were influenced by the learning curve of re-laparoscopy. METHODS A retrospective analysis of patients undergoing LCS and reoperated by a laparoscopic approach during the period 2000-2019 was performed. A cumulative sum analysis was done to determine the number of operations that must be performed to achieve a stable operative time. Based on this analysis, the cohort was divided in 3 groups. Demographics and operative variables were compared between groups. RESULTS From a total of 1911 patients undergoing LCS, 132 (7%) were included. Based on the cumulative sum analysis, the cohort was divided into the first 50 (G1), the following 52 (G2), and the last 30 (G3) patients. Less computed tomography scans were performed in G3 (G1: 72% vs. G2: 63% vs. G3: 43%; P=0.03). There were no differences in the type of operation performed between the groups. The conversion rate (G1: 18% vs. G2: 4% vs. G3: 3%; P=0.02) and the mean operative time (G1: 104 min vs. G2: 80 min vs. G3: 78 min; P=0.003) were higher in G1. Overall morbidity was lower in G3 (G1: 46% vs. G2: 63% vs. G3: 33%; P=0.01). Major morbidity, mortality, and mean length of stay remained similar in all groups. CONCLUSIONS A total of 50 laparoscopic reoperations might be needed to achieve an appropriate learning curve with reduced operative time and lower conversion rates. Further research is needed to determine the learning process of re-laparoscopy for treating complications after colorectal surgery.
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Affiliation(s)
| | | | - Mariano Laporte
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Maximiliano E Bun
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Nicolas A Rotholtz
- Department of Surgery
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic. Updates Surg 2022; 74:1271-1279. [PMID: 35606625 PMCID: PMC9126695 DOI: 10.1007/s13304-022-01283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022]
Abstract
Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.
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14
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Enciu O, Avino A, Calu V, Toma E, Tulin A, Tulin R, Slavu I, Răducu L, Balcangiu‑Stroescu AE, Gheoca Mutu DE, Tomescu L, Miron A. Laparoscopic vs. open resection for colon cancer‑quality of oncologic resection evaluation in a medium volume center. Exp Ther Med 2022; 24:455. [PMID: 35747155 PMCID: PMC9204561 DOI: 10.3892/etm.2022.11382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.
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Affiliation(s)
- Octavian Enciu
- Discipline of General Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Adelaida Avino
- Discipline of Plastic and Reconstructive Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Valentin Calu
- Discipline of General Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Elena Toma
- Discipline of General Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Adrian Tulin
- Discipline of Anatomy, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Raluca Tulin
- Discipline of Anatomy, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Iulian Slavu
- Discipline of Anatomy, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Laura Răducu
- Discipline of Plastic and Reconstructive Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Andra-Elena Balcangiu‑Stroescu
- Discipline of Physiology, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Daniela-Elena Gheoca Mutu
- Department of Plastic and Reconstructive Surgery, Prof. Dr. Agrippa Ionescu Clinical Emergency Hospital, Bucharest 011356, Romania
| | - Luminiţa Tomescu
- Department of Interventional Radiology, Prof. Dr. Agrippa Ionescu Clinical Emergency Hospital, Bucharest 011356, Romania
| | - Adrian Miron
- Discipline of General Surgery, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
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15
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Giani A, Veronesi V, Bertoglio CL, Mazzola M, Bernasconi DP, Grimaldi S, Gualtierotti M, Magistro C, Ferrari G. Multidimensional evaluation of the learning curve for laparoscopic complete mesocolic excision for right colon cancer: a risk-adjusted cumulative summation analysis. Colorectal Dis 2022; 24:577-586. [PMID: 35108445 DOI: 10.1111/codi.16075] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 02/08/2023]
Abstract
AIM Despite the suggested potential benefit of complete mesocolic excision (CME) for right-sided colon cancer (RCC) for patient survival, concerns about its safety and feasibility have contributed to delayed acceptance of the procedure, especially when performed by a minimally invasive approach. Thus, the aim of this work was to evaluate the actual learning curve (LC) of laparoscopic CME for experienced colorectal surgeons. METHOD Prospectively collected data for consecutive patients undergoing laparoscopic CME for RCC between October 2015 and January 2021 at our institution, operated on by experienced surgeons, were analysed. A multidimensional assessment of the LC was performed through cumulative sum (CUSUM) and risk-adjusted (RA) CUSUM analysis. RESULTS Two hundred and two patients operated by on by three surgeons were considered. The CUSUM graphs based on operating time showed one peak of the curve between 17 and 27 cases. The CUSUM graphs based on surgical failure showed one peak of the curve between 20 and 24 cases The RA-CUSUM curve also showed one preeminent peak at 24-33 cases. Based on the CUSUM and RA-CUSUM analyses all the surgeons reached proficiency in 24-33 cases. CONCLUSIONS Our study showed that an experienced minimally invasive colorectal surgeon acquires proficiency in laparoscopic CME for RCC after performing 24-33 cases.
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Affiliation(s)
- Alessandro Giani
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valentina Veronesi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy
| | - Camillo Leonardo Bertoglio
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michele Mazzola
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy.,Department of Advanced Training Research and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Simona Grimaldi
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Monica Gualtierotti
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carmelo Magistro
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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16
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Hahn SJ, Sylla P. Technological Advances in the Surgical Treatment of Colorectal Cancer. Surg Oncol Clin N Am 2022; 31:183-218. [DOI: 10.1016/j.soc.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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17
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Fournier FR, Brown CJ. Transanal Endoscopic Surgery: Who Should Be Doing This Procedure? Clin Colon Rectal Surg 2022; 35:99-105. [PMID: 35237104 PMCID: PMC8885151 DOI: 10.1055/s-0041-1742109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES) was introduced in the 1980s, but more widely adopted in the late 2000s with innovations in instrumentation and training. Moreover, the global adoption of minimally invasive approaches to abdominal procedures has led to translatable skills for TES among colorectal and general surgeons. While there are similarities to laparoscopic surgery, TES has unique challenges related to the narrow confines of intraluminal surgery, angled instrumentation, and relatively uncommon indications limiting the opportunity to practice. The following review discusses the current evidence on TES learning curves, including potential limitations related to the broad adoption of TES by general surgeons. This article aims to provide general recommendations for the safe expansion of TES.
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Affiliation(s)
- François Rouleau Fournier
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carl James Brown
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Address for correspondence Carl James Brown, MD, MSc, FACS, FRCSC Department of Surgery, St. Paul's Hospital, University of British Columbia1081 Burrard Street, Room C310, Third Floor, Burrard Building, Vancouver, BCCanada V6Z 1Y6
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18
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Factors affecting the learning curve in robotic colorectal surgery. J Robot Surg 2022; 16:1249-1256. [DOI: 10.1007/s11701-022-01373-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 01/18/2023]
Abstract
AbstractLearning related to robotic colorectal surgery can be measured by surgical process (such as time or adequacy of resection) or patient outcome (such as morbidity or quality of life). Time based metrics are the most commonly used variables to assess the learning curve because of ease of analysis. With analysis of the learning curve, there are factors which need to be considered because they may have a direct impact on operative times or may be surrogate markers of clinical effectiveness (unrelated to times). Variables which may impact on operation time include surgery case mix, hybrid technique, laparoscopic and open colorectal surgery experience, robotic surgical simulator training, technology, operating room team, and case complexity. Multidimensional analysis can address multiple indicators of surgical performance and include variables such as conversion rate, complications, oncological outcome and functional outcome. Analysis of patient outcome and/or global assessment of robotic skills may be the most reliable methods to assess the learning curve.
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19
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Spinelli A. Colorectal Cancer: Minimally Invasive Surgery. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:619-642. [DOI: 10.1007/978-3-030-66049-9_36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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20
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Akram WM, Vohra N, Irish W, Zervos EE, Wong J. Racial Disparity in the Surgical Management of Diverticular Disease. Am Surg 2021; 88:929-935. [PMID: 34964694 DOI: 10.1177/00031348211058623] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race. METHODS Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race. RESULTS Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001. CONCLUSION There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.
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Affiliation(s)
- Warqaa M Akram
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nasreen Vohra
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - William Irish
- Division of Surgical Research, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Emmanuel E Zervos
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Jan Wong
- Division of Surgical Oncology, Department of Surgery, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
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21
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Vermel M, Lecointre L, Jochum F, Schwaab T, Futcher F, Faller É, Boisramé T, Baldauf JJ, Akladios C. Bowel resection performed by gynecologists - Outcomes and learning curves. Activity profile in a Gynecology Department: 7-year observational cohort. Eur J Obstet Gynecol Reprod Biol 2021; 267:142-149. [PMID: 34773876 DOI: 10.1016/j.ejogrb.2021.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/31/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Bowel resection is frequently used when performing oncological surgery to obtain complete cytoreduction or to remove endometriosis in case of intestinal invasion. Acquiring the surgical skills to perform this kind of procedure is crucial to offer to our patients an optimal management. The aim of this study is to describe a 7-years surgical experience in bowel resections of a gynecologic surgeon and to determine his learning curves. STUDY DESIGN This is a monocentric retrospective cohort study reporting digestive resection performed between January 2013 and April 2020 in the Gynecology Department of Strasbourg University Hospital. Ninety-one consecutive patients were assigned in two groups: gynecological cancer (n = 44) and deep infiltrating endometriosis (DIE) (n = 47). The main outcome measure was the postoperative complications rate at 30 days, based on the modified Clavien-Dindo severity system. Learning curves were evaluated using cumulative sum (CUSUM) analysis of operative time and risk-adjusted cumulative sum (RA-CUSUM) analysis of severe perioperative complications. Identification of predictive factors for operation duration and severe perioperative complication occurrence was conducted using multivariate analysis. RESULTS Minor complications were found in 25% of cases. Major complication rate (Clavien-Dindo ≥ IIIa) was 14% in total and only involved patients operated for cancer. The CUSUM curve for operative time peaked at the 35th case and showed a downward slope after the 45th case. Significant predictive factors of operating time were cytoreductive tumoral surgery, size of the bowel resection and laparoscopic surgery, while learning phase 3 significantly decreased it. The RA-CUSUM curve for severe perioperative complications (Clavien-Dindo ≥ IIIa) showed a progressive decrease in the complication rate as the number of interventions increases without showing clear inflection points. Only cardiopulmonary pathologies were found as significant predictive factor of severe complications. CONCLUSION Proficiency in performing highly complex surgery was achieved after approximately 45 cases, cancer and DIE all together. Acceptable rates of severe perioperative complications were observed even during the initial learning period and are comparable with those found in the literature concerning bowel resection performed by gynecologic oncologists but also by general and digestive surgeons.
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Affiliation(s)
- Muriel Vermel
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Lise Lecointre
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France; I-Cube UMR 7357, laboratoire des Sciences de l'ingénieur, de l'informatique et de l'imagerie, Strasbourg University, Pôle API - Parc d'innovation, 300 boulevard Sébastien Brant - BP 10413, 67412 Illkirch Cedex, France
| | - Floriane Jochum
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Thomas Schwaab
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Françoise Futcher
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Émilie Faller
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Thomas Boisramé
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Jean-Jacques Baldauf
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France
| | - Chérif Akladios
- Gynecology Department, Strasbourg University Hospital, Avenue Molière, 67200 Strasbourg, France.
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22
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Manigrasso M, Vertaldi S, Anoldo P, D’Amore A, Marello A, Sorrentino C, Chini A, Aprea S, D’Angelo S, D’Alesio N, Musella M, Vitiello A, De Palma GD, Milone M. Robotic Colorectal Cancer Surgery. How to Reach Expertise? A Single Surgeon-Experience. J Pers Med 2021; 11:621. [PMID: 34208988 PMCID: PMC8307843 DOI: 10.3390/jpm11070621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/02/2021] [Accepted: 06/28/2021] [Indexed: 12/13/2022] Open
Abstract
The complexity associated with laparoscopic colorectal surgery requires several skills to overcome the technical difficulties related to this procedure. To overcome the technical challenges of laparoscopic surgery, a robotic approach has been introduced. Our study reports the surgical outcomes obtained by the transition from laparoscopic to robotic approach in colorectal cancer surgery to establish in which type of approach the proficiency is easier to reach. Data about the first consecutive 15 laparoscopic and the first 15 consecutive robotic cases are extracted, adopting as a comparator of proficiency the last 15 laparoscopic colorectal resections for cancer. The variables studied are operative time, number of harvested nodes, conversion rate, postoperative complications, recovery outcomes. Our analysis includes 15 patients per group. Our results show that operative time is significantly longer in the first 15 laparoscopic cases (p = 0.001). A significantly lower number of harvested nodes was retrieved in the first 15 laparoscopic cases (p = 0.003). Clavien Dindo I complication rate was higher in the first laparoscopic group, but without a significant difference among the three groups (p = 0.09). Our results show that the surgeon needed no apparent learning curve to reach their laparoscopic standards. However, further multicentric prospective studies are needed to confirm this conclusion.
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Affiliation(s)
- Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Pietro Anoldo
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Carmen Sorrentino
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Salvatore Aprea
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Salvatore D’Angelo
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Nicola D’Alesio
- “Federico II” University Hospital, Via Pansini 5, 80131 Naples, Italy; (S.A.); (S.D.); (N.D.)
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (M.M.); (A.V.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Pansini 5, 80131 Naples, Italy; (S.V.); (P.A.); (A.D.); (A.M.); (C.S.); (A.C.); (G.D.D.P.); (M.M.)
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23
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Franchini Melani AG, Capochin Romagnolo LG. Management of postoperative complications during laparoscopic anterior rectal resection. Minerva Surg 2021; 76:324-331. [PMID: 33944518 DOI: 10.23736/s2724-5691.21.08890-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.
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Affiliation(s)
- Armando G Franchini Melani
- Americas Medical City, Rio de Janeiro, Brazil - .,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil -
| | - Luis G Capochin Romagnolo
- Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil.,Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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24
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Wong SW, Ang ZH, Yang PF, Crowe P. Robotic colorectal surgery and ergonomics. J Robot Surg 2021; 16:241-246. [PMID: 33886064 DOI: 10.1007/s11701-021-01240-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022]
Abstract
Improved ergonomics for the operating surgeon may be an advantage of robotic colorectal surgery. Perceived robotic ergonomic advantages in visualisation include better exposure, three-dimensional vision, surgeon camera control, and line of sight screen location. Postural advantages include seated position and freedom from the constraints of the sterile operating field. Manipulation benefits include articulated instruments with seven degrees of freedom movement, elimination of fulcrum effect, tremor filtration, and scaling of movement. Potential ergonomic detriments of robotic surgery include lack of haptic feedback, visual, and mental strain from increased operating time and interruptions to workflow from crowding.
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Affiliation(s)
- Shing Wai Wong
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia.
- Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia.
| | - Zhen Hao Ang
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Phillip F Yang
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Philip Crowe
- Department of General Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia
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Haddad N, Tsur AM, Nadler R, Glassberg E, Benov A, Chen J. Inexperienced but Confident: A Survey of Advanced Life Support Providers and Life-saving Interventions in the Israel Defense Forces. Mil Med 2021; 186:261-265. [PMID: 33499523 DOI: 10.1093/milmed/usaa465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/24/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks. METHODS This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access. RESULTS During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics. CONCLUSION IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.
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Affiliation(s)
- Nadav Haddad
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel.,The Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Avishai M Tsur
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Roy Nadler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Elon Glassberg
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Avi Benov
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel.,The Azrieli Faculty of Medicine, Bar-ilan University Ramat-gan, 5290002, Israel
| | - Jacob Chen
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
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Efficient and Safe Method for Splenic Flexure Mobilization in Laparoscopic Left Hemicolectomy: A Propensity Score-weighted Cohort Study. Surg Laparosc Endosc Percutan Tech 2020; 31:196-202. [PMID: 33284257 PMCID: PMC8132887 DOI: 10.1097/sle.0000000000000884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/16/2020] [Indexed: 01/20/2023]
Abstract
Supplemental Digital Content is available in the text. Because methods of performing laparoscopic left hemicolectomy differ between surgeons, standardizing the procedure is crucial to reduce complications and secure good oncologic outcomes.
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Gkionis IG, Flamourakis ME, Tsagkataki ES, Kaloeidi EI, Spiridakis KG, Kostakis GE, Alegkakis AK, Christodoulakis MS. Multidimensional analysis of the learning curve for laparoscopic colorectal surgery in a regional hospital: the implementation of a standardized surgical procedure counterbalances the lack of experience. BMC Surg 2020; 20:308. [PMID: 33267802 PMCID: PMC7709341 DOI: 10.1186/s12893-020-00975-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique. Methods From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 – group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups. Results There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083). Conclusions Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.
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Affiliation(s)
- Ioannis G Gkionis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece.
| | - Mathaios E Flamourakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni S Tsagkataki
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni I Kaloeidi
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Konstantinos G Spiridakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Georgios E Kostakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | | | - Manousos S Christodoulakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
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28
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Rintala JM, Tahvonen PR, Vuolio ST, Typpö IT, Suokanerva KA, Huhta HI. The Effect of Laparoscopic Technique on the Surgical Outcome of Colorectal Cancer in a Small-Volume Rural Finnish Lapland Central Hospital. Gastrointest Tumors 2020; 8:16-24. [PMID: 33728292 DOI: 10.1159/000511104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Laparoscopic colorectal surgery has become widely used in treating colorectal cancer. Multicenter studies have shown that laparoscopy decreases postoperative complications and provides equivalent long-term oncological results compared to open surgery. Previous studies were conducted in high-volume institutions, with selected patients, which may influence the reported outcome of laparoscopy. Methods All patients with colorectal cancer that underwent surgery for a primary tumor between 2005 and 2015 in the Lapland Central Hospital were retrospectively collected. We retrieved data on the primary surgical outcome and complications within the first 30 days after surgery from patient records. We surveyed the national patient registry to determine long-term oncological results and patient survival. Results We identified 349 patients treated for colorectal cancer during 2005-2015. Of these, 219 patients (median age 71 years) underwent laparoscopy and 130 (median age 72 years) underwent open surgery. The 5-year disease-specific survival rates for stages I-III colon cancer were 83.3 and 87.7%, respectively. The 3-year disease-specific survival rates for stages I-III rectal cancer were 86.1 and 65.0%, respectively. Conclusion Our results showed that the introduction of laparoscopic colorectal surgery for treating cancer in a rural, small-volume hospital provided short- and long-term results comparable to findings from previous studies conducted in high-volume centers. Therefore, laparoscopy should be considered the treatment of choice for colorectal cancer in small, rural clinics.
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Affiliation(s)
- Jukka M Rintala
- Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland, Oulu, Finland.,Department of Surgery Oulu University Hospital Oulu Finland, Oulu, Finland
| | - Pirita R Tahvonen
- Department of Radiology Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Saija T Vuolio
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Ilpo T Typpö
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Kai A Suokanerva
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Heikki I Huhta
- Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland, Oulu, Finland.,Department of Surgery Oulu University Hospital Oulu Finland, Oulu, Finland
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Amin-Tai H, Elnaim ALK, Wong MPK, Sagap I. Acquiring Advanced Laparoscopic Colectomy Skills - The Issues. Malays J Med Sci 2020; 27:24-35. [PMID: 33154699 PMCID: PMC7605826 DOI: 10.21315/mjms2020.27.5.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/14/2020] [Indexed: 10/28/2022] Open
Abstract
Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England's Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves pre-clinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.
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Affiliation(s)
- Hizami Amin-Tai
- Department of Surgery, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | | | - Michael Pak Kai Wong
- School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ismail Sagap
- Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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30
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Yüksel C, Erşen O, Mercan Ü, Başçeken Sİ, Bakırarar B, Bayar S, Ünal AE, Demirci S. Long-Term Results and Current Problems in Laparoscopic Gastrectomy: Single-Center Experience. J Laparoendosc Adv Surg Tech A 2020; 30:1204-1214. [PMID: 32348706 PMCID: PMC7699011 DOI: 10.1089/lap.2020.0180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: The study aims to evaluate the long-term results of patients who underwent laparoscopic gastrectomy for gastric cancer in Ankara University Medical Faculty, Surgical Oncology Clinic, within 5 years. Materials and Methods: We retrospectively reviewed the data of patients who underwent laparoscopic gastrectomy for gastric cancer at the Surgical Oncology Clinic of Ankara University Medical Faculty between January 2014 and September 2019. One hundred forty-six patients were included in the study. Results: Fifty-one (34.9%) of the patients were female; 95 (65.1%) were male. The mean ± standard deviation and median (minimum-maximum) values of the patients were 60.92 ± 14.13 and 64.00 (22.00-93.00), respectively (Table 1). Eighty-seven (59.6%) cases were located in the antrum, 29 (19.9%) were in the cardia region, and 30 (20.5%) were in the corpus region. Overall, 106 (72.6%) of 146 patients were alive, while 40 (27.4%) were ex. The mean survival was 21.8 months (0-69). Postoperative mortality was seen in 9 patients (6.2%) and our disease-free survival rate was 70.5%. Recurrence occurred in 14 (9.6%) of all patients. [Table: see text] Conclusion: In conclusion, although laparoscopic gastrectomy is a reliable and feasible method for gastric cancer, the standardization of laparoscopic surgery is required in clinics.
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Affiliation(s)
- Cemil Yüksel
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
| | - Ogün Erşen
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
| | - Ümit Mercan
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
| | | | - Batuhan Bakırarar
- Biostatistic Department, Ankara University Medicine Faculty, Ankara, Turkey
| | - Sancar Bayar
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
| | - Ali Ekrem Ünal
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
| | - Salim Demirci
- General Surgery Department, Surgical Oncology Clinic, Ankara University Medicine Faculty, Ankara, Turkey
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31
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Jang JH, Kim CN. Robotic Total Mesorectal Excision for Rectal Cancer: Current Evidences and Future Perspectives. Ann Coloproctol 2020; 36:293-303. [PMID: 33207112 PMCID: PMC7714377 DOI: 10.3393/ac.2020.06.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Despite the technical limitations of minimally invasive surgery, laparoscopic total mesorectal excision (LTME) for rectal cancer has short-term advantages over open surgery, but the pathological outcomes reported in randomized clinical trials are still in controversy. Minimally invasive robotic total mesorectal excision (RTME) has recently been gaining popularity as robotic surgical systems potentially provide greater benefits than LTME. Compared to LTME, RTME is associated with lower conversion rates and similar or better genitourinary functions, but its long-term oncological outcomes have not been established. Although the operating time of RTME is longer than that of LTME, RTME has a shorter learning curve, is more convenient for surgeons, and is better for sphincter-preserving operations than LTME. The robotic surgical system is a good technical tool for minimally invasive surgery for rectal cancer, especially in male patients with narrow deep pelvises. Robotic systems and robotic surgical techniques are still improving, and the contribution of RTME to the treatment of rectal cancer will continue to increase in the future.
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Affiliation(s)
- Je-Ho Jang
- Department of Surgery, Eulji University School of Medicine, Daejeon, Korea
| | - Chang-Nam Kim
- Department of Surgery, Eulji University School of Medicine, Daejeon, Korea
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32
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Bracale U, Merola G, Pignata G, Corcione F, Pirozzi F, Cuccurullo D, De Palma GD, Cassinotti E, Sciuto A, Boni L. Laparoscopic resection with complete mesocolic excision for splenic flexure cancer: long-term follow-up data from a multicenter retrospective study. Surg Endosc 2020; 34:2954-2962. [PMID: 31451917 DOI: 10.1007/s00464-019-07078-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Splenic flexure cancer (SFC), identified as tumors raised in the distal transverse colon and proximal descending colon, accounts for 2 to 5% of all surgically treated colorectal cancers. Despite the fact that the laparoscopic approach has become the gold standard for many colorectal procedures, it has never been extensively investigated in SFC due to lack of an agreed consensus on the appropriate operative procedure. The aim of this multicenter retrospective study is to evaluate the oncologic value of laparoscopic segmental resection with complete mesocolic excision (CME) for cancer located in the splenic flexure. METHODS All data of consecutive patients who had undergone laparoscopic resection with CME for SFC from January 2005 to December 2017 at five different tertiary centers were retrospectively analyzed. The Kaplan-Meier (KM) test was used to assess the overall survival (OS) and the disease-free survival (DFS) rates after surgery. Univariate Cox regression was used to explore the association between OS and other independent factors. RESULTS Recurrence was observed in 13 (11.6%) patients and a significant association between disease stage and recurrence (P < 0.001) was found with a higher proportion of stage IV patients in the recurrence group (46.1% vs. 7.1%). During a median follow-up of 43 months (range 12-149), 13 deaths occurred, all of them due to disease progression. KM curves for all stages showed an estimated survival rate of 51% at 148 months. CONCLUSION Laparoscopic segmental resection with CME appears to be an oncologically safe and effective procedure for treatment of SFC and may be considered as a standard surgical method for elective management of the disease. In the future, routine lymph node mapping could be used to confirm this hypothesis.
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Affiliation(s)
- Umberto Bracale
- Department Gastroenterology, Endocrinology and Surgical Endoscopy, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy.
| | - Giovanni Merola
- Department Gastroenterology, Endocrinology and Surgical Endoscopy, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Giusto Pignata
- Department of General Surgery II, Spedali Civili, Brescia, Italy
- Department of General and Mininvasive Surgery, San Camillo Hospital, Trento, Italy
| | - Francesco Corcione
- Department Gastroenterology, Endocrinology and Surgical Endoscopy, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
- Department of General Surgery, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Diego Cuccurullo
- Department of General Surgery, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Giovanni Domenico De Palma
- Department Gastroenterology, Endocrinology and Surgical Endoscopy, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Elisa Cassinotti
- Department of General Surgery, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Luigi Boni
- Department of General Surgery, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Yamamoto M, Okuda J, Tanaka K, Kondo K, Asai K, Kayano H, Masubuchi S, Uchiyama K. Evaluating the Learning Curve Associated with Laparoscopic Left Hemicolectomy for Colon Cancer. Am Surg 2020. [DOI: 10.1177/000313481307900424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The role of laparoscopic surgery for transverse and descending colon cancer remains controversial. The aim of the present study was to characterize the learning curve for laparoscopic left hemicolectomy including the splenic flexure and to identify factors that influence this learning curve. Data from 120 consecutive patients undergoing laparoscopic left hemicolectomy for transverse and descending colon cancer including the splenic flexure between December 1996 and December 2009 were analyzed. Patients undergoing resection combined with cholecystectomy, hepatectomy, hysterectomy, or gastrectomy were excluded. Operative time was analyzed using the moving average method. The operative time, conversion rate, and postoperative complication rate were evaluated among four groups based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery were analyzed. Operative time for left hemicolectomy decreased with increasing case number with stabilization at 30 cases. There was no significant difference in the conversion rate or postoperative complications over time. Significant factors for conversion to open surgery were T stage (odds ratio [OR], 5.56; 95% confidence interval [CI], 1.5 to 27.4) and previous abdominal surgery (OR, 5.38; 95% CI, 1.6 to 20.2). The learning curve for laparoscopic left hemicolectomy is steep. Thus, surgeons in the early part of this curve should carefully select patients to allow them to build experience in a stepwise manner. Laparoscopic surgery may become the gold standard for management of colon cancer regardless of stage or tumor location.
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Affiliation(s)
- Masashi Yamamoto
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Junji Okuda
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Keitaro Tanaka
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Keisaku Kondo
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Keiko Asai
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Hajime Kayano
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Shinsuke Masubuchi
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Kazuhisa Uchiyama
- From the Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
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34
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Bracale U, Merola G, Rizzuto A, Pontecorvi E, Silvestri V, Pignata G, Pirozzi F, Cuccurullo D, Sciuto A, Corcione F. Does a 3D laparoscopic approach improve surgical outcome of mininvasive right colectomy? A retrospective case-control study. Updates Surg 2020; 72:445-451. [PMID: 32232743 DOI: 10.1007/s13304-020-00755-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022]
Abstract
Laparoscopy has gained wide acceptance due its benefits for patients. However, advanced laparoscopic procedures are still challenging. One critical issue is lack of stereoscopic vision. Despite its diffusion, the totally laparoscopic approach for right hemicolectomy (TLRC) is still debated due to its difficulty, particularly for fashioning of the ileocolic anastomosis. The aim of this multicenter study is to investigate whether 3D vision offers any advantages on surgical performance over 2D vision during TLRC. All data of consecutive patients who underwent elective TLRC for cancer at three Italian surgical centers with either 2D or 3D technology from January 2013 to December 2018 were retrieved from a computer-maintained database. A case-matched analysis using the Mantel-Haenszel method was performed. After matching, a total of 106 patients were analyzed with 53 patients in each group. Mean operative time was significantly longer for 2D-TLRC than for 3D-TLRC (153.2 ± 52.4 vs. 131 ± 51 min, p = 0.029) and a statistically significant difference in anastomosing time (p = 0.032, 19.2 ± 5.9 min vs. 21.7 ± 6.2 min for 3D and 2D group, respectively) was also recorded. No difference in the median number of harvested nodes (23 ± 11 vs. 21 ± 7 for 3D and 2D group, respectively; p = 0.48) was found. Neither intraoperative complications nor conversions occurred in the two groups. In conclusion, 3D vision appears to improve the performance of a TLRC by reducing operative time and making intracorporeal anastomosis easier. Prospective randomized studies are required to determine the real beneficial effects.
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Affiliation(s)
- Umberto Bracale
- Department of General Surgery and Specialities, School of Medecine Federico II of Naples, Via Pansini 5, 7th Building, Naples, Italy.
| | - Giovanni Merola
- Department of General Surgery and Specialities, School of Medecine Federico II of Naples, Via Pansini 5, 7th Building, Naples, Italy
| | - Antonia Rizzuto
- Medical and Surgical Science, University "Magna Graecia" of Catanzaro Medical School, Catanzaro, Italy
| | - Emanuele Pontecorvi
- Department of General Surgery and Specialities, School of Medecine Federico II of Naples, Via Pansini 5, 7th Building, Naples, Italy
| | - Vania Silvestri
- Department of General Surgery and Specialities, School of Medecine Federico II of Naples, Via Pansini 5, 7th Building, Naples, Italy
| | - Giusto Pignata
- Department of General Surgery II, Spedali Civili of Brescia, Brescia, Italy
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Diego Cuccurullo
- Department of General Surgery, Ospedali dei Colli Monaldi Hospital, Naples, Italy
| | - Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Francesco Corcione
- Department of General Surgery and Specialities, School of Medecine Federico II of Naples, Via Pansini 5, 7th Building, Naples, Italy
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35
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Hoogerboord M, Ellsmere J, Caycedo-Marulanda A, Brown C, Jayaraman S, Urbach D, Cleary S. Laparoscopic colectomy: trends in implementation in Canada and globally. Can J Surg 2019. [PMID: 30907994 DOI: 10.1503/cjs.003118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Summary Comparisons with other high-income countries suggest that Canada has been slower to adopt laparoscopic colectomy (LC). The Canadian Association of General Surgeons sought to evaluate the barriers to adoption of laparoscopic colon surgery and to propose potential intervention strategies to enhance the use of the procedure. Given the clinical benefits of laparoscopic surgery for patients, the increasing needs for surgical care and the desire of Canadian general surgeons to advance their specialty and enhance the care of their patients, it is an important priority to improve the utilization of LC.
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Affiliation(s)
- Marius Hoogerboord
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - James Ellsmere
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - Antonio Caycedo-Marulanda
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - Carl Brown
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - Shiva Jayaraman
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - David Urbach
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
| | - Sean Cleary
- From the Division of General Surgery, Department of Surgery, Dalhousie University, Halifax, NS (Hoogerboord, Ellsmere); the Division of General Surgery, Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ont. (Caycedo-Marulanda); the Division of General Surgery, Department of Surgery, University of British Columbia, Vancouver, BC (Brown); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Jayaraman, Urbach); the Department of Surgery, St. Joseph’s Health Centre, Toronto, Ont. (Jayaraman); the Department of Surgery, Women’s College Hospital, Toronto, Ont. (Urbach); and the Department of Surgery, Mayo Clinic, Rochester, MN (Cleary)
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Robotic Surgery for Rectal Cancer and Cost-Effectiveness. JOURNAL OF MINIMALLY INVASIVE SURGERY 2019; 22:139-149. [PMID: 35601368 PMCID: PMC8980152 DOI: 10.7602/jmis.2019.22.4.139] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 02/01/2023]
Abstract
Robotic surgery is considered as one of the advanced treatment modality of minimally invasive surgery for rectal cancer. Robotic rectal surgery has been performed for three decades and its application is gradually expanding along with technology development. It has several technical advantages which include magnified three-dimensional vision, better ergonomics, multiple articulated robotic instruments, and the opportunity to perform remote surgery. The technical benefits of robotic system can help to manipulate more meticulously during technical challenging procedures including total mesorectal excision in narrow pelvis, lateral pelvic node dissection, and intersphincteric resection. It is also reported that robotic rectal surgery have been shown more favorable postoperative functional outcomes. Despite its technical benefits, a majority of studies have been reported that there is rarely clinical or oncologic superiority of robotic surgery for rectal cancer compared to conventional laparoscopic surgery. In addition, robotic rectal surgery showed significantly higher costs than the standard method. Hence, the cost-effectiveness of robotic rectal surgery is still questionable. In order for robotic rectal surgery to further develop in the field of minimally invasive surgery, there should be an obvious cost-effective advantages over laparoscopic surgery, and it is crucial that large-scale prospective randomized trials are required. Positive competition of industries in correlation with technological development may gradually reduce the price of the robotic system, and it will be helpful to increase the cost-effectiveness of robotic rectal surgery.
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Quality Improvement in Laparoscopic Donor Nephrectomy by Self-Imposed Proctored Preceptorship Model. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01912-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Fujii S, Akagi T, Inomata M, Katayama H, Mizusawa J, Ota M, Saito S, Kinugasa Y, Yamaguchi S, Sato T, Kitano S. Transitional impact of short- and long-term outcomes of a randomized controlled trial to evaluate laparoscopic versus open surgery for colorectal cancer from Japan Clinical Oncology Group Study JCOG0404. Ann Gastroenterol Surg 2019; 3:301-309. [PMID: 31131359 PMCID: PMC6524094 DOI: 10.1002/ags3.12245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The JCOG0404 randomized controlled trial conducted to compare laparoscopic surgery (LAP) with open surgery (OP) for stage II/III colon cancer showed better short-term outcomes and equal long-term outcomes of LAP versus OP. Technical instrumentation of surgery and anticancer agents given during the registration period might have affected the outcomes. AIM To evaluate outcomes according to the registration periods. METHODS The overall registration period was divided into three periods (first: 2004-2005, second: 2006-2007 and third: 2008-2009). Short-term and long-term outcomes were compared between registration periods. RESULTS In total, 1057 patients were registered. Numbers of patients undergoing each approach for each of the three periods (1st/2nd/3rd) were 528 for OP (106/244/178) and 529 for LAP (106/246/177). Operation time (minutes) did not change between the periods for OP (160/156/161) or LAP (205/211/219). Blood loss (mL) gradually decreased in the latter two periods: (119/80/75) for OP and (35/28/25) for LAP. Incidence of complications (%) decreased in the latter periods for OP (27.6/20.3/21.3), whereas that for LAP remained consistently low (14.3/14.8/13.6). There was no particular trend in 5-year overall survival and recurrence-free survival depending on the period regardless of treatment. D3 dissection rates were 95% or more for all periods in both groups. CONCLUSIONS Operation time and survival rates did not change over time, whereas blood loss in OP improved in the latter periods. Quality control applied in this trial might have been effective in producing such safe endpoints. (ClinicalTrials.gov, number NCT00147134, UMIN Clinical Trials Registry, number C000000105.).
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Affiliation(s)
- Shoichi Fujii
- Department of Gastroenterological SurgeryYokohama City University Medical CenterYokohamaJapan
| | - Tomonori Akagi
- Department of Gastroenterological and Pediatric SurgeryOita UniversityOitaJapan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric SurgeryOita UniversityOitaJapan
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer CenterTokyoJapan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer CenterTokyoJapan
| | - Mitsuyoshi Ota
- Department of Gastroenterological SurgeryYokohama City University Medical CenterYokohamaJapan
| | - Shuji Saito
- Division of Colon and Rectal SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Yusuke Kinugasa
- Division of Colon and Rectal SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Shigeki Yamaguchi
- Division of Colon and Rectal SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Takeo Sato
- Department of SurgeryKitasato University HospitalSagamiharaJapan
| | - Seigo Kitano
- Department of Gastroenterological and Pediatric SurgeryOita UniversityOitaJapan
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Käser SA, Rickenbacher A, Cabalzar-Wondberg D, Schneider M, Dietrich D, Misselwitz B, Clavien PA, Turina M. The growing discrepancy between resident training in colonic surgery and the rising number of general surgery graduates. Int J Colorectal Dis 2019; 34:423-429. [PMID: 30523397 DOI: 10.1007/s00384-018-3209-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The decrease in resident operative experience due to working-hour directives and sub-specialization within general surgery is the subject of growing debate. This study aims to examine how the numbers of colectomies used for resident training have evolved since the introduction of working-hour directives and to place these results within the context of the number of new general surgeons. METHODS Based on the nationwide database of the Swiss association for quality management in surgery, all segmental colectomies performed at 86 centers were analyzed according to the presence or absence of residents and compared to national numbers of surgical graduates. RESULTS Of 19,485 segmental colectomies between 2006 and 2015, 36% were used for training purposes. Residents performed 4%, junior staff surgeons 31%, senior staff surgeons 55%, and private surgeons 10%. The percentage performed by residents decreased significantly, while the annual number of graduates increased from 36 to 79. Multivariate analysis identified statutory (non-private) health insurance (OR 7.6, CI 4.6-12.5), right colon resection (OR 3.5, CI 2.5-4.7), tertiary referral center (OR 1.9, CI 1.5-2.6), emergency surgery (OR 1.7, CI 1.3-2.3), and earlier date of surgery (OR 1.1, CI 1.0-1.1) as predictors for resident involvement. CONCLUSIONS Only a low and declining percentage of colectomies is used for resident training, despite growing numbers of trainees. These data imply that opportunities to obtain technical proficiency have diminished since the implementation of working-hour directives, indicating the need to better utilize suitable teaching opportunities, to ensure that technical proficiency remains high.
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Affiliation(s)
- Samuel A Käser
- Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - Andreas Rickenbacher
- Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | | | - Marcel Schneider
- Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - Daniel Dietrich
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - Matthias Turina
- Department of Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland.
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Feasibility of hand-assisted laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy. Surg Endosc 2019; 33:52-57. [PMID: 29926165 DOI: 10.1007/s00464-018-6265-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 06/07/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND In light of the modern surgical trend towards minimally invasive surgery, we aim to assess the feasibility of hand-assisted laparoscopic (HAL) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal surface malignancy (PSM). METHODS Patients with PSM secondary to colorectal cancer or pseudomyxoma peritonei with peritoneal cancer index (PCI) of ≤ 10 were considered for HAL CRS and HIPEC. One patient had PCI of 15 but based on the disease distribution laparoscopic-assisted CRS and HIPEC was thought to be feasible, thus was also included. These patients were compared to matched controls who underwent open CRS and HIPEC for similar pathologies. Matching was performed on age and PCI to reflect a comparable complexity of the operation, and tumor grade for comparable risk of disease recurrence. RESULTS Eleven patients were included in each group. In both groups, mean PCI was 4.1, mean age was 58.5 years, and 81.8% were well-moderately differentiated tumors. Complete cytoreduction was achieved in all patients. Upon comparison, HAL patients had significantly less blood loss and 3-day shorter hospitalization. No difference was demonstrated in operative time, number of visceral resections, and rate of omentectomy/peritonectomy. Also, no difference was detected in morbidities and 30-day readmission rates. No intraperitoneal recurrences have been reported in the HAL group after a median follow-up of 11 months. CONCLUSION HAL CRS and HIPEC is a feasible procedure and can be considered for PSM with low PCI. It offers very acceptable and comparable short-term outcomes to the conventional open approach.
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Unguryan VM, Babich AI, Pobedintseva YA, Kudlachev VA, Kruglov EA. Implementation of laparoscopic approach in colorectal cancer surgery — a single center’s experience. COLORECTAL ONCOLOGY 2018. [DOI: 10.17650/2220-3478-2018-8-4-60-64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Upper extremity surface electromyography signal changes after laparoscopic training. Wideochir Inne Tech Maloinwazyjne 2018; 13:485-493. [PMID: 30524619 PMCID: PMC6280082 DOI: 10.5114/wiitm.2018.78744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/02/2018] [Indexed: 01/28/2023] Open
Abstract
Introduction Objective measures of laparoscopic skill in training are lacking. Aim To evaluate the changes in the surface electromyography (sEMG) signal during laparoscopic training, and to link them to intracorporeal knot tying. Material and methods Ten right-handed medical students (6 female), aged 25 ±0.98, without training in laparoscopy, were enrolled in the study. With no additional training, they tied intracorporeal single knots for 15 min. Then underwent laparoscopic training and redid the knot tying exercise. During both events, sEMG was recorded from 8 measurement points on the upper extremities and neck bilaterally. We analyzed changes in sEMG resulting from training and tried to find sEMG predictive parameters for higher technical competence defined by the number of knots tied after the training. Results The average number of knots increased after the training. Significant decreases in activity after the training were visible for the non-dominant hand deltoid and trapezius muscles. Dominant and non-dominant hands had different activation patterns. Differences largely disappeared after the training. All muscles, except for the dominant forearm and non-dominant thenar, produced a negative correlation between their activities and the number of tied knots. The strongest anticorrelation occurred for the non-dominant deltoid (r = –0.863, p < 0.05). Relatively strong relationships were identified in the case of the non-dominant trapezius and forearm muscles (r = –0.587, r = –0.504). Conclusions At least for some muscle groups there is a change in activation patterns after laparoscopic training. Proximal muscle groups tend to become more relaxed and the distal ones become more active. Changes in the non-dominant hand are more pronounced than in the dominant hand.
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Martel G, Boushey RP, Marcello PW. Reprint of: Results of the laparoscopic colon cancer randomized trials: An evidence-based review. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Leijssen LGJ, Dinaux AM, Kunitake H, Bordeianou LG, Berger DL. Is There a Drawback of Converting a Laparoscopic Colectomy in Colon Cancer? J Surg Res 2018; 232:595-604. [PMID: 30463779 DOI: 10.1016/j.jss.2018.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/19/2018] [Accepted: 07/13/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic resection is well established in the treatment of colon cancer. However, conversion rates remain high and the impact of conversion is disputed. MATERIAL AND METHODS We retrospectively identified 1347 patients who underwent surgery for colon cancer between 2004 and 2014 at our tertiary center. Morbidity and oncological outcomes were compared between patients who underwent successfully completed laparoscopic surgery (LS), planned open surgery (OS), and conversion to open surgery (CS). Long-term analysis included patients with stage I-III disease. In addition, we performed propensity score matching to adjust for the heterogeneity and selection bias between the treatment groups. RESULTS Of all patients, 505 underwent LS, 789 underwent OS, and 53 underwent CS, which corresponded to a conversion rate of 9.5%. Conversion was associated with male gender, left-sided tumors, and stage III disease. Length of stay, morbidity, and readmission rates were lower for LS patients. Kaplan-Meier curves demonstrated worse overall, disease-specific, and disease-free survival in CS than LS, with similar outcomes to OS. However, after propensity score matching, CS was only associated with admission duration and the requirement of blood transfusion, whereas survival outcomes were comparable between all groups. CONCLUSIONS CS is associated with adverse short- and long-term outcomes compared to LS. However, when accounting for differences in baseline and pathologic features, CS remained only associated with a longer length of stay and more blood transfusions. Because outcomes were comparable between CS and OS, regardless of stage and other risk factors, our data support a surgeon's attempt to perform LS in patients with colon cancer.
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Affiliation(s)
- Lieve G J Leijssen
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne M Dinaux
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hiroko Kunitake
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Liliana G Bordeianou
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David L Berger
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Aselmann H, Kersebaum JN, Bernsmeier A, Beckmann JH, Möller T, Egberts JH, Schafmayer C, Röcken C, Becker T. Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a significantly higher quality of TME specimen compared to the laparoscopic approach-report of a single-center experience. Int J Colorectal Dis 2018; 33:1575-1581. [PMID: 29971488 DOI: 10.1007/s00384-018-3111-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 02/07/2023]
Abstract
AIM Robotic surgery allows for a better visualization and more precise dissection especially in the narrow male pelvis and mid and lower third of the rectum. However, superiority to laparoscopic TME has yet to be proven. We therefore analyzed short-term outcomes of laparoscopic and robotic low anterior rectal resection for rectal cancer. PATIENTS AND METHODS From 2011 to 2016, 44 robotic (RTME) and 41 laparoscopic (LTME) low anterior rectal resection with total mesorectal excision were performed at a single institution. Specimen quality was assessed and reported by an independent pathologist following international guidelines. RESULTS The groups did not differ significantly regarding gender, age, ASA stage, BMI, and distance of the lower tumor margin from the anal verge. More patients in the RTME group underwent preoperative chemoradiation (43.2 vs. 19.5%, p = 0.019). The quality of the TME specimen was significantly better in the RTME group (complete/nearly complete/incomplete for RTME 97/0/3% and for LTME 78/17/5%, p = 0.03). The conversion rate tended to be lower in the RTME group (7 vs. 17%, p = 0.143). There was no difference in CRM positivity between the groups. CONCLUSION Robotic surgery is safe and can improve the quality of TME for rectal cancer compared to laparoscopy. Any effect on long-term survival remains to be established.
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Affiliation(s)
- Heiko Aselmann
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Jan-Niclas Kersebaum
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Alexander Bernsmeier
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jan Henrik Beckmann
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Thorben Möller
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jan Hendrik Egberts
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Clemens Schafmayer
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Christoph Röcken
- Institut für Pathologie, Christian Albrechts Universität zu Kiel und Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Klinik für Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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Horie H, Koinuma K, Ito H, Sadatomo A, Naoi D, Kono Y, Inoue Y, Morimoto M, Tahara M, Lefor AK, Sata N, Sasaki T, Sugimoto H. Utility of preoperative 3-D simulation of laparoscopic lateral pelvic lymph node dissection for advanced rectal cancer: Surgical outcomes of 10 initial cases. Asian J Endosc Surg 2018. [PMID: 29532610 DOI: 10.1111/ases.12476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Laparoscopic lateral pelvic lymph node dissection (LPLD) is technically challenging because of the complicated anatomy of the pelvic wall. To overcome this difficulty, we introduced preoperative 3-D simulation. The aim of the study is to investigate the usefulness of preoperative 3-D simulation for the safe conduct of laparoscopic LPLD for rectal cancer. METHODS After undergoing colonoscopy, patients were brought to the radiology suite where multi-detector row CT was performed. Three-dimensional images were constructed at a workstation and showed branches of the iliac artery and vein, ureter, urinary bladder, and enlarged lymph nodes. All members of the surgical team participated in preoperative simulation using the 3-D images. RESULTS A total of 10 patients with advanced lower rectal cancer and enlarged lateral pelvic lymph nodes underwent laparoscopic unilateral LPLD after total mesorectal excision, tumor-specific mesorectal excision, or total proctocolectomy. Four of the 10 patients (40%) had variations in pelvic vascular anatomy. The median operative time for unilateral LPLD was 91 min (range, 66-142 min) and gradually declined, suggesting a good learning curve. The median number of lateral pelvic lymph nodes harvested was nine (range, 3-16). The median estimated blood loss was 13 mL (range, 10-160 mL). No conversion to open surgery or intraoperative complications occurred. No patient had major postoperative complications. CONCLUSION Preoperative 3-D simulation may be useful for the safe conduct of laparoscopic LPLD, especially for surgeons with limited prior experience.
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Affiliation(s)
- Hisanaga Horie
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Koji Koinuma
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Homare Ito
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Ai Sadatomo
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Daishi Naoi
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yoshihiko Kono
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yoshiyuki Inoue
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | | | - Makiko Tahara
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Alan K Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Takahiro Sasaki
- Department of Radiology, Jichi Medical University, Shimotsuke, Japan
| | - Hideharu Sugimoto
- Department of Radiology, Jichi Medical University, Shimotsuke, Japan
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Abstract
BACKGROUND AND OBJECTIVES In this study, we examined the consistency, rapidity, and reproducibility of the ABCDE technique for diaphragm identification. Operators using this method place the probe at the Anterior axillary line, watch for Breathing (lung sliding), and then move the probe Caudally to identify the Diaphragm for Examination. METHODS A convenience sample of 100 patients was recruited from the preadmission clinic. Two novice operators each scanned the diaphragm using a linear ultrasound transducer in B-mode. Both operators completed the examination on all participants using the ABCDE technique, their times were averaged, and clinical success was defined as identification of the diaphragm in less than 2 minutes. RESULTS An average of 33.7 seconds was taken to scan and identify the right hemidiaphragm (RD) (median, 25 seconds; 95% confidence interval, 28.8-38.5 seconds) with a 98% clinical success ratio, and an average of 46.9 seconds was taken to identify the left hemidiaphragm (LD) (median, 39.5 seconds; 95% confidence interval, 40.2-53.6 seconds) with a 97% clinical success ratio. In patients with a body mass index (BMI) of less than 30 kg/m, a 100% success ratio was seen when scanning the RD and 97% when scanning the LD. For those with a BMI of 30 kg/m or greater, a 94% success rate was seen when scanning the RD and 97% when scanning the LD. No clinically significant differences were found between the times required for scanning either side of the diaphragm, regardless of the BMI. CONCLUSIONS The ABCDE technique demonstrates a fast, reliable, and simple method in which ultrasound can be used to visualize the diaphragm.
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Milone M, Angelini P, Berardi G, Burati M, Corcione F, Delrio P, Elmore U, Lemma M, Manigrasso M, Mellano A, Muratore A, Pace U, Rega D, Rosati R, Tartaglia E, De Palma GD. Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients. Surg Endosc 2018; 32:3467-3473. [PMID: 29344788 DOI: 10.1007/s00464-018-6065-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 01/12/2018] [Indexed: 12/13/2022]
Abstract
Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4; p = 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days; p < 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6; p < 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2-20; p = 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5-23, p = 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1-16.9; p = 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.
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Affiliation(s)
- Marco Milone
- University of Naples "Federico II", Napoli, Italy.
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via Pansini 5, 80131, Napoli, Italy.
| | | | | | | | | | - Paolo Delrio
- Fondazione Giovanni Pascale Cancer Institute, IRCCS, Napoli, Italy
| | - Ugo Elmore
- San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | - Maria Lemma
- San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | | | | | | | - Ugo Pace
- Fondazione Giovanni Pascale Cancer Institute, IRCCS, Napoli, Italy
| | - Daniela Rega
- Fondazione Giovanni Pascale Cancer Institute, IRCCS, Napoli, Italy
| | - Riccardo Rosati
- San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
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Increased Postoperative Morbidity Associated With Prolonged Laparoscopic Colorectal Resections Is Not Increased by Resident Involvement. Dis Colon Rectum 2018. [PMID: 29528909 DOI: 10.1097/dcr.0000000000000934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although longer operative times are associated with increased postoperative morbidity, the influence of surgical residents on this association is unclear. OBJECTIVE The purpose of this study was to evaluate whether morbidity associated with operative times in laparoscopic colorectal surgery is increased by resident training. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using a national database. PATIENTS Laparoscopic ileocolectomies, partial colectomies, and low anterior resections were identified in the National Surgical Quality Improvement Project (2005-2012). This cohort was stratified by the presence of resident involvement (postgraduate clinical year ≤5) and then divided into tertiles of operative time (low, medium, and high), allowing comparisons of cases by duration with resident involvement with cases of similar length without resident involvement. MAIN OUTCOME MEASURES Postoperative morbidity (infectious and noninfectious), length of hospital stay, and unplanned reoperations were the primary study outcomes. RESULTS A total of 20,785 procedures were identified. In aggregate, prolonged operative time was associated with both infectious (OR = 1.49, p < 0.001 with residents; OR = 1.38, p < 0.001 without residents) and noninfectious complications (OR = 1.51, p < 0.001 with residents; OR = 1.48, p < 0.001 without residents) when compared with short cases without residents. Longer hospital stay was observed both within the highest (additional 1.2 days (p < 0.001) with residents; 1.1 days (p < 0.001) without residents) and middle (additional 0.4 days (p < 0.001) with residents; 0.4 days (p = 0.001) without residents) tertiles of operative time. Within the highest tertile of operative length, there was no statistically significant difference in complication rates between cases with and without resident participation. LIMITATIONS The study was limited by its retrospective design and inability to define the complexity of case and extent of resident involvement. CONCLUSIONS Although longer operative times confer increased postoperative morbidity, there was no significant difference in complication rates within the highest tertile between cases with and without resident participation. Resident involvement does not appear to add to the risk of morbidity associated with longer and more complicated surgeries. See Video Abstract at http://links.lww.com/DCR/A440.
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