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Lesi OK, Igho-Osagie E, Bashir N, Kumar S, Probert S, Sakthipakan M, Constantino L, Paratharajan S, Ahmad S, Haque SU. Outcomes Following Colorectal Cancer Surgeries at the Basildon and Thurrock University Hospital. Cureus 2024; 16:e61261. [PMID: 38939296 PMCID: PMC11210995 DOI: 10.7759/cureus.61261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/29/2024] Open
Abstract
Aim We reviewed surgical outcomes for patients with colorectal cancer resections in Basildon and Thurrock University Hospital between April 2019 and March 2020. Methods Clinical characteristics of 141 patients who underwent surgical resection for colorectal cancer at the district hospital were assessed and reported, including tumor site, disease stage, and type of surgical resection performed. We reviewed 30- and 90-day postoperative mortality, postoperative complications, return to the theater, and extended hospital stay data for these patients. The results of our review across measured outcomes were compared to the national average from the National Bowel Cancer Audit (NBOCA) Report. Results Clinical data and health outcomes for 141 patients with colorectal cancer resections within the index year were reviewed. The mean age at diagnosis was 68.9 (12.5) years. Among the patients, 61 (43.3%) were female, and 59 (41.8%) had Stage III and IV colorectal cancer. Around 95 (67.4%) had the colon as the primary tumor site, while 46 (32.6%) had the primary tumor site in the rectum. Of the patients, 17 (12.1%) had emergency surgeries, and 124 (87.9%) underwent laparoscopic surgery. Right hemicolectomy was the most common operation performed in 58 patients (41.1%). The average length of stay was 7.8 (6.6) days; the length of stay was similar for both colonic and rectal resections. Low 30-day and 90-day mortality rates of (1/141) 0.71% and (2/141) 1.4%, respectively, were observed compared to the 90-day United Kingdom (UK) national average mortality rate of 2.7% in 2019/20. Around 30 (21.3%) of the patients developed postoperative complications within 30 days of surgery. Only six out of 30 postoperative complications were classified as Clavien-Dindo Grade III. Conclusion Surgical outcomes for patients with colorectal cancer in our district general hospital are similar to or lower than the national averages estimated by NBOCA. To further strengthen surgical care delivery and improve patient outcomes in the United Kingdom, there is a need to improve surgical techniques and quality improvement processes.
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Affiliation(s)
- Omotara Kafayat Lesi
- General and Colorectal Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
| | | | - Nida Bashir
- Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Shashi Kumar
- General Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Spencer Probert
- General Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
| | | | | | | | - Suliman Ahmad
- Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
| | - Samer-Ul Haque
- Surgery, Basildon and Thurrock University Hospital, Basildon, GBR
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Buitrago-Ruiz M, Martinez-Nicolas I, Soria-Aledo V. Validation of prolonged length of stay as a reliable measure of failure to rescue in colorectal surgery. Asian J Surg 2023; 46:126-131. [PMID: 35317966 DOI: 10.1016/j.asjsur.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/10/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Failure-to-rescue measures a hospital's response capacity to avoid the death of a patient after a complication. The aim of this study was to validate the use of prolonged length of stay to calculate failure-to-rescue rates as a substitute for traditional coding of complications in colorectal cancer surgery. METHOD We performed a cross-sectional between-instruments agreement study. Our study population was comprised of 204 colorectal cancer surgical patients from a public academic hospital during 2017 and 2018. We obtained two failure-to-rescue indicators from administrative data: an indicator using International Classification of Diseases, tenth edition, (ICD-10) codes; and another one using a cut-off point of prolonged length of stay as a predictor of patients with complications. Then, they were compared with a reference indicator from clinical records. RESULTS Failure-to-rescue rates were between 10 and 13.64 for the study site depending on which indicator was used. A hospital stay ≥10 days had the maximum Youden's index (0.6) and an area under the ROC curve of 0.87. This was used in the failure-to-rescue indicator using prolonged length, which obtained the highest agreement (any coefficient >0.75). CONCLUSION ICD-10 codes identified complications poorly. Prolonged length of stay could be a valid replacement of ICD-10 codes when measuring failure-to-rescue in administrative databases for colorectal surgical patients.
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Affiliation(s)
| | | | - Victor Soria-Aledo
- Morales Meseguer General University Hospital Murcia, Spain; Surgery Department, University of Murcia Murcia, Spain; Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain.
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3
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Shin J, Kim ER, Jang HJ, Baek DH, Yang DH, Lee BI, Cho KB, Cho JW, Jung SA, Hong SJ, Ko BM, Jeon JW, Ko WJ, Kim SM, Kim YD, Gyoo KC, Baik GH, Yoo IK, Nyeong LK, Lee SH, Lim CH, Jeon SW. Long-term prognosis of curative endoscopic submucosal dissection for early colorectal cancer according to submucosal invasion: a multicenter cohort study. BMC Gastroenterol 2022; 22:417. [PMID: 36100888 PMCID: PMC9469604 DOI: 10.1186/s12876-022-02499-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Endoscopic submucosal dissection (ESD) can provide a high en bloc resection rate and has been widely applied as curative treatment for early colorectal cancer (ECC). However, surgical treatment is occasionally required, and reports on the long-term prognosis of ESD are insufficient. This study aimed to investigate the long-term outcomes of ECC removal by ESD, including local recurrence and metastasis. Methods This multicenter study was conducted retrospectively on 450 consecutive patients with ECC who were treated with ESD between November 2003 and December 2013. Clinical, pathological, and endoscopic data were collected to determine tumor depth, resection margin, lymphovascular invasion, and recurrence. Results The median follow-up period was 53.8 (12–138 months). The en bloc resection rate was 85.3% (384) and in intramucosal cancer being 84.1% and in superficial submucosal invasion (SM1) cancer being 89.8% (p = 0.158). The curative resection rate was 76.0% (n = 342), and there was no statistical difference between the two groups (77.3% vs. 71.4%, p = 0.231). The overall recurrence free survival rate (RFS) was 98.7% (444/450). In patients with curative resection, there was no statistically significant difference in RFS according to invasion depth (intramucosal: 99.3% vs. SM1: 97.1%, p = 0.248). Conclusions Patients with curatively resected ECC treated with ESD showed favorable long-term outcomes. Curatively resected SM1 cancer has a RFS similar to that of intramucosal cancer.
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Chakrabarti S, Peterson CY, Sriram D, Mahipal A. Early stage colon cancer: Current treatment standards, evolving paradigms, and future directions. World J Gastrointest Oncol 2020; 12:808-832. [PMID: 32879661 PMCID: PMC7443846 DOI: 10.4251/wjgo.v12.i8.808] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/16/2020] [Accepted: 08/01/2020] [Indexed: 02/05/2023] Open
Abstract
Colon cancer continues to be one of the leading causes of mortality and morbidity throughout the world despite the availability of reliable screening tools and effective therapies. The majority of patients with colon cancer are diagnosed at an early stage (stages I to III), which provides an opportunity for cure. The current treatment paradigm of early stage colon cancer consists of surgery followed by adjuvant chemotherapy in a select group of patients, which is directed at the eradication of minimal residual disease to achieve a cure. Surgery alone is curative for the vast majority of colon cancer patients. Currently, surgery and adjuvant chemotherapy can achieve long term survival in about two-thirds of colon cancer patients with nodal involvement. Adjuvant chemotherapy is recommended for all patients with stage III colon cancer, while the benefit in stage II patients is not unequivocally established despite several large clinical trials. Contemporary research in early stage colon cancer is focused on minimally invasive surgical techniques, strategies to limit treatment-related toxicities, precise patient selection for adjuvant therapy, utilization of molecular and clinicopathologic information to personalize therapy and exploration of new therapies exploiting the evolving knowledge of tumor biology. In this review, we will discuss the current standard treatment, evolving treatment paradigms, and the emerging biomarkers, that will likely help improve patient selection and personalization of therapy leading to superior outcomes.
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Affiliation(s)
- Sakti Chakrabarti
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Carrie Y Peterson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Deepika Sriram
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, United States
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Napolitano MA, Skancke M, Walters J, Michel L, Randall JA, Brody FJ, Duncan JE. Outcomes and Trends in Colorectal Surgery in U.S. Veterans: A 10-year Experience at a Tertiary Veterans Affairs Medical Center. J Laparoendosc Adv Surg Tech A 2020; 30:378-382. [DOI: 10.1089/lap.2019.0739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Matthew Skancke
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC
| | - Jarvis Walters
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC
| | - Lynn Michel
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC
| | - J. Alex Randall
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Fredrick J. Brody
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC
| | - James E. Duncan
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC
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Becattini C, Pace U, Rondelli F, Delrio P, Ceccarelli G, Boncompagni M, Graziosi L, Visonà A, Chiari D, Avruscio G, Frasson S, Gussoni G, Biancafarina A, Camporese G, Donini A, Bucci AF, Agnelli G. Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY. Eur J Intern Med 2020; 72:53-59. [PMID: 31818628 DOI: 10.1016/j.ejim.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern. METHODS PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups. DISCUSSION The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.
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Affiliation(s)
- Cecilia Becattini
- Department of Internal and Cardiovascular Medicine and Stroke Unit, University of Perugia, Italy.
| | - Ugo Pace
- National Cancer Institute, "G. Pascale" Foundation, Napoli, Italy.
| | - Fabio Rondelli
- Department of General Surgery, S. Giovanni Battista Hospital, Foligno, Italy.
| | - Paolo Delrio
- National Cancer Institute, "G. Pascale" Foundation, Napoli, Italy.
| | | | - Michela Boncompagni
- Department of General Surgery, S. Maria della Misericordia Hospital, Perugia, Italy.
| | - Luigina Graziosi
- Department of Oncology Surgery, University of Perugia, Perugia, Italy.
| | - Adriana Visonà
- Department of Vascular Medicine, S.Giacomo Apostolo Hospital, Catelfranco Veneto, Treviso, Italy.
| | - Damiano Chiari
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy.
| | - Giampiero Avruscio
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Angiology, University Hospital of Padua, Padua, Italy.
| | | | | | | | - Giuseppe Camporese
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Angiology, University Hospital of Padua, Padua, Italy.
| | - Annibale Donini
- Department of Oncology Surgery, University of Perugia, Perugia, Italy.
| | | | - Giancarlo Agnelli
- Department of Internal and Cardiovascular Medicine and Stroke Unit, University of Perugia, Italy.
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Sack J, Steinberg JA, Rennert RC, Hatefi D, Pannell JS, Levy M, Khalessi AA. Initial Experience Using a High-Definition 3-Dimensional Exoscope System for Microneurosurgery. Oper Neurosurg (Hagerstown) 2019; 14:395-401. [PMID: 29106670 DOI: 10.1093/ons/opx145] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/22/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The operative microscope and endoscope have significantly advanced modern neurosurgery. These devices are nonetheless limited by high costs and suboptimal optics, ergonomics, and maneuverability. A recently developed extracorporeal telescope ("exoscope") operative system combines characteristics from both the operative microscope and endoscope and provides an affordable, portable, high-definition operative experience. Widespread use of exoscopes in neurosurgery has previously been limited by a lack of stereopsis with 2-dimensional(2-D) monitors. OBJECTIVE To assess the surgical potential of a novel, 3-D, high-definition (4K-HD) exoscope system. METHODS Assess dissection time and visualization of critical structures in a series of human cadaveric cranial neurosurgical approaches with the 3-D 4K-HD exoscope as compared to a standard operating microscope. RESULTS Dissection times and visualization of critical structures was comparable with the 3-D 4K-HD exoscope and a standard operating microscope. The low-profile exoscope nonetheless allowed for larger operative corridors, enhanced instrument maneuverability, and less obstruction in passing instrumentation. The large monitor also resulted in an immersive surgical experience, and gave multiple team members the same high-quality view as the primary operator. Finally, the exoscope possessed a more ergonomically favorable setup as compared to the traditional microscope, allowing the surgeon to be in a neutral position despite the operative angle. CONCLUSION The novel 3-D 4K-HD exoscope system possesses favorable optics, ergonomics, and maneuverability as compared to the traditional operating microscope, with the exoscope's shared surgical view possessing obvious educational and workflow advantages. Further clinical trials are justified to validate this initial cadaveric experience.
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Affiliation(s)
- Jayson Sack
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Dustin Hatefi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Jeffrey S Pannell
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Michael Levy
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California
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8
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Impact of Approach and Hospital Volume on Cardiovascular Complications After Pulmonary Lobectomy. J Surg Res 2019; 235:202-209. [DOI: 10.1016/j.jss.2018.09.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/20/2018] [Accepted: 09/20/2018] [Indexed: 01/25/2023]
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Van Dalen ASHM, Ali UA, Murray ACA, Kiran RP. Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis. Am Surg 2019. [DOI: 10.1177/000313481908500230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.
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Affiliation(s)
| | - Usama Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alice C. A. Murray
- Department of Colorectal Surgery, Columbia University Medical Centre, New York, New York
| | - Ravi Pokala Kiran
- Department of Colorectal Surgery, Columbia University Medical Centre, New York, New York
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Eisenstein S, Stringfield S, Holubar SD. Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery. Clin Colon Rectal Surg 2019; 32:41-53. [PMID: 30647545 DOI: 10.1055/s-0038-1673353] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.
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Affiliation(s)
- Samuel Eisenstein
- Section of Colon and Rectal Surgery, Rebecca and John Moores Cancer Center, University of California San Diego Health, La Jolla, California
| | - Sarah Stringfield
- Section of Colon and Rectal Surgery, Rebecca and John Moores Cancer Center, University of California San Diego Health, La Jolla, California
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Bailón-Cuadrado M, Pérez-Saborido B, Sánchez-González J, Rodríguez-López M, Velasco-López R, C Sarmentero-Prieto J, I Blanco-Álvarez J, Pacheco-Sánchez D. Prognostic Nutritional Index predicts morbidity after curative surgery for colorectal cancer. Cir Esp 2018; 97:71-80. [PMID: 30583791 DOI: 10.1016/j.ciresp.2018.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/12/2018] [Accepted: 08/30/2018] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is a major health concern and it is associated with significant morbidity and mortality. Over the last decades, the relationship between cancer and nutritional and inflammatory status in oncologic patients was studied thoroughly and multiple immunonutritional scores were developed. These scores have been mainly related to the prognosis of several cancers. An interaction between the tumour and the host is generated, triggering a systemic inflammatory reaction leading to several neuroendocrine changes. This situation favours a tendency towards anorexia and catabolism. Our hypothesis is that nutritional and inflammatory status of oncologic patients is correlated to postoperative morbidity. METHODS This is a prospective observational cohort study with those patients undergoing curative surgery for CRC at our institution between September 2015 and March 2017. Nutritional and inflammatory status was established using Onodera's Prognostic Nutritional Index (PNI). Complications (overall, severe, infectious and anastomotic leakage) were carefully collected during the first 30 days of the postoperative period. RESULTS After carrying out the multivariate analysis, PNI turned out to be a great predictive and protective factor for overall complications (RR: 0.279; 95% CI: 0.141-0.552), severe complications (RR: 0.355; 95% CI: 0.130-0.965), infectious complications (RR: 0.220; 95% CI: 0.099-0.489) and anastomotic leakage (RR: 0.151; 95% CI: 0.036-0.640). CONCLUSION Our work reports that PNI is an independent predictive factor for the development of postoperative complications following curative surgery for CRC.
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Affiliation(s)
- Martín Bailón-Cuadrado
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España.
| | - Baltasar Pérez-Saborido
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Javier Sánchez-González
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Mario Rodríguez-López
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Rosalía Velasco-López
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José C Sarmentero-Prieto
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José I Blanco-Álvarez
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - David Pacheco-Sánchez
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
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13
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Iwasaki Y, Ishizuka M, Takagi K, Hachiya H, Shibuya N, Nishi Y, Aoki T, Kubota K. A high preoperative Glasgow prognostic score predicts a high likelihood of conversion from laparoscopic to open surgery in patients with colon cancer. Surg Endosc 2018; 33:1111-1116. [PMID: 30046949 PMCID: PMC6430750 DOI: 10.1007/s00464-018-6369-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/20/2018] [Indexed: 02/07/2023]
Abstract
Background Although the use of laparoscopic resection for colon cancer (LRC) has been increasing, conversion to open surgery sometimes becomes necessary because of intraoperative difficulties. Although the Glasgow prognostic score (GPS) is well known to be a predictor of outcome in patients with various cancers, it is unclear whether the preoperative GPS can predict the need for conversion from laparoscopic to open surgery. Objective To investigate factors predictive of conversion from laparoscopic to open surgery in patients with colon cancer. Methods Data from 308 consecutive patients who underwent LRC between January 2006 and March 2017 were retrospectively enrolled. Preoperative clinical factors in patients who had undergone LRC were compared between conversion and non-conversion groups, and multivariate regression analysis was performed to identify preoperative factors that might predict conversion from laparoscopic to open surgery. Results Among 308 patients who had undergone LRC, conversion to open surgery was necessary in 28 (9.1%). Sixteen of the latter patients (6.8%) had GPS 0 (among a total of 234) and 6 (11.5%) had GPS 1 (among a total of 52). The proportion of patients with GPS 2 who required conversion was 27.2% (6/22), which was significantly higher than for those with GPS 0 or 1. Multivariate analysis demonstrated that GPS 2 (odds ratio [OR] 3.352; 95% confidence interval [CI] 1.049–10.71; p = 0.041) and preoperative ileus (OR 7.405; 95% CI 2.386–22.98; p = 0.001) were independent factors predictive of conversion from laparoscopic to open surgery. Conclusions A high preoperative GPS is an independent factor predictive of conversion from laparoscopic to open surgery in patients with colon cancer.
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Affiliation(s)
- Yoshimi Iwasaki
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan.
| | - Mitsuru Ishizuka
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Kazutoshi Takagi
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Hiroyuki Hachiya
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Norisuke Shibuya
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Yusuke Nishi
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Taku Aoki
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Keiichi Kubota
- Department of Gastroenterological Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
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What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review. Int J Colorectal Dis 2018; 33:663-681. [PMID: 29623415 DOI: 10.1007/s00384-018-3036-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND "Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery. METHODS A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed. RESULTS Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact. CONCLUSIONS NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.
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Rectal Dissection Simulator for da Vinci Surgery: Details of Simulator Manufacturing With Evidence of Construct, Face, and Content Validity. Dis Colon Rectum 2018. [PMID: 29521834 DOI: 10.1097/dcr.0000000000001044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Apprenticeship in training new surgical skills is problematic, because it involves human subjects. To date there are limited inanimate trainers for rectal surgery. OBJECTIVE The purpose of this article is to present manufacturing details accompanied by evidence of construct, face, and content validity for a robotic rectal dissection simulation. DESIGN Residents versus experts were recruited and tested on performing simulated total mesorectal excision. Time for each dissection was recorded. Effectiveness of retraction to achieve adequate exposure was scored on a dichotomous yes-or-no scale. Number of critical errors was counted. Dissection quality was tested using a visual 7-point Likert scale. The times and scores were then compared to assess construct validity. Two scorer results were used to show interobserver agreement. A 5-point Likert scale questionnaire was administered to each participant inquiring about basic demographics, surgical experience, and opinion of the simulator. Survey data relevant to the determination of face validity (realism and ease of use) and content validity (appropriateness and usefulness) were then analyzed. SETTINGS The study was conducted at a single teaching institution. SUBJECTS Residents and trained surgeons were included. INTERVENTION The study intervention included total mesorectal excision on an inanimate model. MAIN OUTCOME MEASURES Metrics confirming or refuting that the model can distinguish between novices and experts were measured. RESULTS A total of 19 residents and 9 experts were recruited. The residents versus experts comparison featured average completion times of 31.3 versus 10.3 minutes, percentage achieving adequate exposure of 5.3% versus 88.9%, number of errors of 31.9 versus 3.9, and dissection quality scores of 1.8 versus 5.2. Interobserver correlations of R = 0.977 or better confirmed interobserver agreement. Overall average scores were 4.2 of 5.0 for face validation and 4.5 of 5.0 for content validation. LIMITATIONS The use of a da Vinci microblade instead of hook electrocautery was a study limitation. CONCLUSIONS The pelvic model showed evidence of construct validity, because all of the measured performance indicators accurately differentiated the 2 groups studied. Furthermore, study participants provided evidence for the simulator's face and content validity. These results justify proceeding to the next stage of validation, which consists of evaluating predictive and concurrent validity. See Video Abstract at http://links.lww.com/DCR/A551.
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Chen CF, Lin YC, Tsai HL, Huang CW, Yeh YS, Ma CJ, Lu CY, Hu HM, Shih HY, Shih YL, Sun LC, Chiu HC, Wang JY. Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer. J Minim Access Surg 2018; 14:321-334. [PMID: 29483373 PMCID: PMC6130178 DOI: 10.4103/jmas.jmas_155_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)– laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I–III CRC resection. Patients and Methods: This study enrolled 688 patients with Stage I–III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR). Results: Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05). Conclusions: Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.
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Affiliation(s)
- Chin-Fan Chen
- Department of Surgery, Division of Trauma and Critical Care, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chieh Lin
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Hsiang-Lin Tsai
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Department of Surgery, Division of Trauma and Critical Care; Division of Colorectal Surgery; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Department of Surgery, Division of Colorectal Surgery; Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Kaohsiung, Taiwan
| | - Chien-Yu Lu
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ying-Ling Shih
- Department of Surgery, Nutrition Support Team; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Chu Sun
- Department of Surgery, Nutrition Support Team; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Herng-Chia Chiu
- Research Education and Epidemiology Centre, Changhua Christian Hospital, Changhua; Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University; Research Center for Environmental Medicine, Kaohsiung Medical University; Research Center for Natural Products and Drug Development, Kaohsiung Medical University, Kaohsiung, Taiwan
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Assessing the economic advantage of laparoscopic vs. open approaches for colorectal cancer by a propensity score matching analysis. Surg Today 2017; 48:439-448. [PMID: 29110090 DOI: 10.1007/s00595-017-1606-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/21/2017] [Indexed: 12/17/2022]
Abstract
PURPOSES This study investigated the surgical outcomes and potential economic advantage of open vs. laparoscopic surgery for colorectal cancer using a propensity score matching analysis. METHODS We examined the surgical and economic outcomes of patients undergoing laparoscopic (N = 127) and open surgery (N = 253) for colorectal cancer and then compared these outcomes in two groups (N = 103 each) using a propensity score matching analysis. RESULTS Compared to open surgery, the laparoscopic approach was associated with a significantly lower overall morbidity rate (14 vs. 40%; P < 0.001) and shorter mean (± standard deviation) postoperative hospital stay (12.6 ± 8.3 vs. 16.8 ± 9.9 days, respectively; P = 0.001). Despite generating higher mean surgical costs (Japanese yen) (985,000 ± 215,000 vs. 812,000 ± 222,000 yen; P < 0.001), utilizing a laparoscopic approach significantly reduced the non-surgical costs (773,000 ± 440,000 vs. 1075,000 ± 508,000 yen; P < 0.001). The mean total cost of laparoscopic-assisted surgery (1758,000 ± 576,000 yen) was decreased by approximately 130,000 yen compared with open surgery (1886,000 ± 619,000 yen), although the difference was not statistically significant (P = 0.125). CONCLUSIONS Laparoscopic surgery for colorectal cancer is advantageous in reducing morbidity and facilitating an early discharge and does not increase hospital costs. These findings are consistent with the general consensus supporting the benefits of laparoscopic surgery as a minimally invasive approach.
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Gani F, Cerullo M, Zhang X, Canner JK, Conca-Cheng A, Hartzman AE, Husain SG, Cirocco WC, Traugott AL, Arnold MW, Johnston FM, Pawlik TM. Effect of surgeon “experience” with laparoscopy on postoperative outcomes after colorectal surgery. Surgery 2017; 162:880-890. [DOI: 10.1016/j.surg.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/23/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
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Etter K, Davis B, Roy S, Kalsekar I, Yoo A. Economic Impact of Laparoscopic Conversion to Open in Left Colon Resections. JSLS 2017; 21:JSLS.2017.00036. [PMID: 28890650 PMCID: PMC5565639 DOI: 10.4293/jsls.2017.00036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Studies have shown economic and clinical advantages of laparoscopic left-colon resections. Laparoscopic conversion to open is an important surgical outcome. We estimated conversion incidence, identified risk factors, and measured the clinical and economic impact. METHODS In this retrospective study, we used the Premier Perspective database to analyze left-sided colectomies from 2009 to 2014. Operating room time (ORT), length of stay (LOS), total hospital cost (2014 U.S. dollars); along with incidence of in-hospital clinical outcomes (anastomotic leak surrogate [Leak], transfusion, and mortality) were evaluated. Multivariable models accounting for hospital clustering were used to identify conversion risk factors and analyze the effect of conversion on economic and clinical outcomes. RESULTS A total of 41,417 patients: 8,468 left hemicolectomy and 32,949 sigmoidectomy were identified. Lap-Conversion incidence was 13.3% (95% CI, 12.9-13.7). Adjusted mean LOS (±SE) days was significantly lower for the Lap-Successful group (4.9 compared with Lap-Conversion 6.8 and Open-Planned 7.0), but Lap-Conversion and Open-Planned had similar LOS. Adjusted mean cost was higher for Lap-Conversion $20,165 compared to Open-Planned $18,797; but this difference was smaller than the cost savings for Lap-Successful $16,206 ± $219. Open-Planned had lower odds of Leak compared to Lap-Conversion. Open-Planned and Lap-Conversion had similar odds of transfusion and mortality. Conversion risk factors included inflammatory bowel disease and left-hemicolectomy. Colorectal specialists were associated with 38% decreased odds of conversion. CONCLUSIONS Successful laparoscopic surgery was the most cost effective, with decreased LOS and odds of blood transfusion, leak surrogate, and mortality. Conversion was the most expensive and had increased odds of leak surrogate, but similar LOS compared to Open-Planned. The beneficial effect size of successful laparoscopic surgery was larger than the negative effect of conversion compared to Open-Planned.
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Affiliation(s)
- Katherine Etter
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Brad Davis
- CMC Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sanjoy Roy
- Global Health Economics and Market Access, Ethicon Inc., Somerville, New Jersey, USA
| | - Iftekhar Kalsekar
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Andrew Yoo
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
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Luo Y, Qiu YE, Mu YF, Qin SL, Qi Y, Zhong M, Yu MH, Ma LY. Plastic wound protectors decreased surgical site infections following laparoscopic-assisted colectomy for colorectal cancer: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e7752. [PMID: 28906360 PMCID: PMC5604629 DOI: 10.1097/md.0000000000007752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Laparoscopic surgery is widespread and safe for the management of patients with colorectal cancer (CRC). Although the use of standard surgical techniques can prevent perioperative wound infections, surgical site infections (SSIs) remain an unresolved complication in laparoscopic-assisted colectomy. The present study investigated the ability of plastic wound protectors applied to the extraction incision during the externalized portion of the procedure to reduce the rate of infection in laparoscopic-assisted colectomy. We completed a retrospective review of the medical records of patients who underwent nonemergent laparoscopic-assisted between January 2015 and June 2016. Outcomes for patients with and without the use of a wound protector were compared. A total of 109 patients were included in this study. There was 1 patient in the wound protector group (n = 57) and 7 in the nonwound protector group (n = 52) who developed a wound infection at the colon extraction site (P = .02). Furthermore, the average postoperative hospital stay in the wound protector group was shorter compared to the nonwound protector group (7.47 ± 0.24 vs 8.73 ± 0.54 days, P = .03). In conclusion, this study indicates that the use of a plastic wound protector during laparoscope-assisted colectomy does reduce postoperative wound infection rates, and the wound protectors are beneficial for specimen extraction and digestive tract reconstruction.
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Cerdán Santacruz C, Frasson M, Flor-Lorente B, Ramos Rodríguez JL, Trallero Anoro M, Millán Scheiding M, Maseda Díaz O, Dujovne Lindenbaum P, Monzón Abad A, García-Granero Ximenez E. Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study. Surg Endosc 2017; 31:5032-5042. [PMID: 28455773 DOI: 10.1007/s00464-017-5548-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. METHODS This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. RESULTS 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). CONCLUSIONS In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.
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Affiliation(s)
- Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - Marta Trallero Anoro
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | | | | | | | - Eduardo García-Granero Ximenez
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
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Leraas HJ, Ong CT, Sun Z, Adam MA, Kim J, Gilmore BF, Ezekian B, Nag US, Mantyh CR, Migaly J. Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients. J Gastrointest Surg 2017; 21:684-691. [PMID: 28083836 DOI: 10.1007/s11605-016-3350-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/30/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Hand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique. METHODS We queried the 2012-2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach. RESULTS This query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p < 0.001), and total abdominal colectomy (OR 10.39, p < 0.001). Younger age, black race, ASA class ≥3, inflammatory bowel disease, and low pelvic anastomosis were predictive of OC (all p < 0.05). HALS demonstrated reduced overall complications (p < 0.001), wound complications (p < 0.001), anastomotic leak (p = 0.014), transfusion (p < 0.001), postoperative ileus (p < 0.001), length of stay (p < 0.001), and readmission (p < 0.001) without increased operative time. For segmental resection, HALS demonstrated reduced overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion, length of stay, and readmissions (all p < 0.05). CONCLUSIONS Compared to OC, HALS demonstrates improved perioperative outcomes without increased operative time.
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Affiliation(s)
- Harold J Leraas
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA.
| | - Cecilia T Ong
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Zhifei Sun
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Jina Kim
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Brian Ezekian
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Uttara S Nag
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Christopher R Mantyh
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - John Migaly
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
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The impact of age on complications, survival, and cause of death following colon cancer surgery. Br J Cancer 2017; 116:389-397. [PMID: 28056465 PMCID: PMC5294480 DOI: 10.1038/bjc.2016.421] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/04/2016] [Accepted: 11/13/2016] [Indexed: 01/29/2023] Open
Abstract
Background: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. Methods: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I–III colon cancer resections (2004–2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65–74, ⩾75), complications, 1-year survival, and cause of death. Results: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65–74: HR=1.59, 95% CI=1.26–2.00; ⩾75: HR=2.57, 95% CI=2.09–3.16; sepsis: HR=2.58, 95% CI=2.13–3.11) and cardiovascular disease-specific death (65–74: HR=3.72, 95% CI=2.29–6.05; ⩾75: HR=7.02, 95% CI=4.44–11.10; sepsis: HR=2.33, 95% CI=1.81–2.99). Conclusions: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.
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Groene SA, Chandrasekera CV, Prasad T, Lincourt AE, Heniford BT, Augenstein VA. Right Versus Left-Sided Colectomies: A Comparison of Outcomes. Am Surg 2016. [DOI: 10.1177/000313481608200722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgeons often consider that a right colectomy (RC) carries less risk than a left or sigmoid colectomy (L/SC). Our aim was to compare outcomes between RC and L/SC. Review of the Carolinas Medical Center National Surgical Quality Improvement Program data from 2013 to February 2015 was performed. Procedures were categorized as RC versus L/SC based on current procedural terminology codes for both open and laparoscopic colectomies. Demographics and minor and major complications were evaluated using standard statistical methods. A total of 164 RC and 211 L/SC were studied. RC patients were older (63.9 ± 14.2 vs 59.4 ± 13.0, P < 0.001). Patients undergoing RC had more comorbidities, and 64.6 per cent had an American Society of Anesthesiologist (ASA) Class III or above versus 51.7 per cent of those undergoing L/SC ( P = 0.02). RC had significantly higher rates of postop urinary tract infection (7.3% vs 2.8%, P = 0.04) and postop transfusions ( P = 0.01). Average length of stay was longer for RC (10.1 ± 8.6 days vs 8.3 ± 7.0 days, P < 0.01). After controlling for ASA class, preoperative hematocrit and surgical technique (lap versus open), multivariate analysis indicated that there were no longer any significant differences in outcomes between RC and L/SC. There were no differences between the group complications including superficial or deep surgical site infections, anastomotic leak, myocardial infarction (MI), pneumonia, or 30-day mortality. RC patients tended to be sicker and had more medical complications postop with initial evaluation of the data. However, when controlling for ASA, hematocrit, and techniques, there were no differences in complications when RC was compared to L/SC. The belief that L/SC has a higher rate of complications compared to RC is not supported.
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Affiliation(s)
- Steven A. Groene
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Chamath V. Chandrasekera
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Amy E. Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Vedra A. Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
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Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume. Dis Colon Rectum 2016; 59:535-42. [PMID: 27145311 DOI: 10.1097/dcr.0000000000000580] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown. OBJECTIVE The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time. DESIGN This was a retrospective study. SETTINGS This study was conducted in a tertiary referral hospital. PATIENTS Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status. MAIN OUTCOME MEASURES In-hospital mortality and postoperative complications of surgery were measured. RESULTS A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic). LIMITATIONS This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting. CONCLUSIONS Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.
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Papageorge CM, Zhao Q, Foley EF, Harms BA, Heise CP, Carchman EH, Kennedy GD. Short-term outcomes of minimally invasive versus open colectomy for colon cancer. J Surg Res 2016; 204:83-93. [PMID: 27451872 DOI: 10.1016/j.jss.2016.04.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 03/18/2016] [Accepted: 04/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer. MATERIALS AND METHODS Patients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach-open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups. RESULTS A total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001). CONCLUSIONS This retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.
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Affiliation(s)
- Christina M Papageorge
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Eugene F Foley
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bruce A Harms
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Charles P Heise
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Evie H Carchman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gregory D Kennedy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Sheetz KH, Norton EC, Birkmeyer JD, Dimick JB. Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy. Health Serv Res 2016; 52:56-73. [PMID: 26990210 DOI: 10.1111/1475-6773.12482] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy. DATA SOURCES National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy. STUDY DESIGN Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy. PRINCIPAL FINDINGS Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy. CONCLUSIONS This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
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Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Klugsberger B, Haas D, Oppelt P, Neuner L, Shamiyeh A. Current State of Laparoscopic Colonic Surgery in Austria: A National Survey. J Laparoendosc Adv Surg Tech A 2015; 25:976-81. [PMID: 26599418 DOI: 10.1089/lap.2015.0373] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Several studies have demonstrated that laparoscopic colonic resection has significant benefits in comparison with open approaches in patients with benign and malignant disease. The proportion of colonic and rectal resections conducted laparoscopically in Austria is not currently known; the aim of this study was to evaluate the current status of laparoscopic colonic surgery in Austria. MATERIALS AND METHODS A questionnaire was distributed to all general surgical departments in Austria. In collaboration with IMAS, an Austrian market research institute, an online survey was used to identify laparoscopic and open colorectal resections performed in 2013. The results were compared with data from the National Hospital Morbidity Database (NHMD), in which administrative in-patient data were also collected from all general surgical departments in Austria in 2013. RESULTS Fifty-three of 99 surgical departments in Austria responded (53.5%); 4335 colonic and rectal resections were carried out in the participating departments, representing 50.5% of all NHMD-recorded colorectal resections (n = 8576) in Austria in 2013. Of these 4335 colonic and rectal resections, 2597 (59.9%) were carried out using an open approach, 1674 (38.6%) were laparoscopic, and an exact classification was not available for 64 (1.5%). Among the NHMD-recorded colonic and rectal resections, 6342 (73.9%) were carried out with an open approach, and 2234 (26.1%) were laparoscopic. CONCLUSIONS The proportion of colorectal resections that are carried out laparoscopically is low (26.1%). Technical challenges and a learning curve with a significant number of cases may be reasons for the slow adoption of laparoscopic colonic surgery.
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Affiliation(s)
- Bettina Klugsberger
- 1 Second Surgical Department, Kepler University Hospital , Linz, Austria .,2 Linz Training and Research Center for Surgery and Oncology, Kepler University Hospital , Linz, Austria
| | - Dietmar Haas
- 3 Department of Obstetrics and Gynecology, Kepler University Hospital , Linz, Austria .,4 Department of Gynecology, Erlangen University Hospital , Erlangen, Germany
| | - Peter Oppelt
- 3 Department of Obstetrics and Gynecology, Kepler University Hospital , Linz, Austria .,4 Department of Gynecology, Erlangen University Hospital , Erlangen, Germany
| | - Ludwig Neuner
- 5 Department of Anesthesiology and Intensive Care, Freistadt General Hospital , Freistadt, Austria
| | - Andreas Shamiyeh
- 1 Second Surgical Department, Kepler University Hospital , Linz, Austria .,2 Linz Training and Research Center for Surgery and Oncology, Kepler University Hospital , Linz, Austria
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Surgical Unit volume and 30-day reoperation rate following primary resection for colorectal cancer in the Veneto Region (Italy). Tech Coloproctol 2015; 20:31-40. [PMID: 26573812 DOI: 10.1007/s10151-015-1388-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of Surgical Unit volume on the 30-day reoperation rate in patients with CRC. METHODS Data were extracted from the regional Hospital Discharge Dataset and included patients who underwent elective resection for primary CRC in the Veneto Region (2005-2013). The primary outcome measure was any unplanned reoperation performed within 30 days from the index surgery. Independent variables were: age, gender, comorbidity, previous abdominal surgery, site and year of the resection, open/laparoscopic approach and yearly Surgical Unit volume for colorectal resections as a whole, and in detail for colonic, rectal and laparoscopic resections. Multilevel multivariate regression analysis was used to evaluate the impact of variables on the outcome measure. RESULTS During the study period, 21,797 elective primary colorectal resections were performed. The 30-day reoperation rate was 5.5% and was not associated with Surgical Unit volume. In multivariate multilevel analysis, a statistically significant association was found between 30-day reoperation rate and rectal resection volume (intermediate-volume group OR 0.75; 95% CI 0.56-0.99) and laparoscopic approach (high-volume group OR 0.69; 95% CI 0.51-0.96). CONCLUSIONS While Surgical Unit volume is not a predictor of 30-day reoperation after CRC resection, it is associated with an early return to the operating room for patients operated on for rectal cancer or with a laparoscopic approach. These findings suggest that quality improvement programmes or centralization of surgery may only be required for subgroups of CRC patients.
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Turrado-Rodriguez V, Targarona Soler E, Bollo Rodriguez JM, Balagué Ponz C, Hernández Casanovas P, Martínez C, Trías Folch M. Are there differences between right and left colectomies when performed by laparoscopy? Surg Endosc 2015; 30:1413-8. [DOI: 10.1007/s00464-015-4345-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 05/04/2015] [Indexed: 12/22/2022]
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Luglio G, De Palma GD, Tarquini R, Giglio MC, Sollazzo V, Esposito E, Spadarella E, Peltrini R, Liccardo F, Bucci L. Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study. Ann Med Surg (Lond) 2015; 4:89-94. [PMID: 25859386 PMCID: PMC4388911 DOI: 10.1016/j.amsu.2015.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, "learning curve" experience, implementing a well standardized operative technique and recovery protocol. METHODS The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. RESULTS Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo-Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. CONCLUSION Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.
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Affiliation(s)
- Gaetano Luglio
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
- Center of Excellence for Technical Innovation in Surgery (CEITC), Italy
| | - Rachele Tarquini
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Emanuela Esposito
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Emanuela Spadarella
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Roberto Peltrini
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Filomena Liccardo
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
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Peters MG, Bartlett EK, Roses RE, Kelz RR, Fraker DL, Karakousis GC. Age-Related Morbidity and Mortality with Cytoreductive Surgery. Ann Surg Oncol 2015; 22 Suppl 3:S898-904. [PMID: 26014156 DOI: 10.1245/s10434-015-4624-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cytoreduction and intraperitoneal chemotherapy (IPC) are increasingly considered in older patients. We sought to better characterize the influence of age on 30-day outcomes following this procedure. METHODS The ACS NSQIP database was queried for patients who underwent IPC and a concurrent intra-abdominal operation (2005-2012). Thirty-day death and serious morbidity (DSM) was the primary outcome. Trends in DSM by age were defined using Joinpoint regression. Univariate and multivariate logistic regression identified factors associated with DSM. RESULTS In 1085 patients, DSM increased at a significant rate after age 50 (0.6 %/year, p = 0.001). Patients ≥60 (n = 376) represented 35 % of the study population. Age ≥60 years was independently associated with DSM (odds ratio [OR] 1.6, p = 0.001). The older patient population (≥60 years) experienced 44 % morbidity and 3.2 % mortality. In these patients, preoperative weight loss, low preoperative albumin, splenectomy, intraoperative transfusion, contaminated or dirty wound classification, and prolonged operative time were all independently significantly associated with increased DSM. In the absence of these factors (n = 45), the DSM rate was 11 %. Rates of DSM increased to 33, 63, and 100 % in patients with 1 factor, 2-3 factors, and 4 or more factors (n = 14; p < 0.001), respectively. Venous thromboembolism, sepsis, postoperative bleeding, and respiratory complications were significantly more common among those aged 60 years and older (p < 0.05 each). CONCLUSIONS The risk of DSM increases with age in patients undergoing cytoreduction and IPC. Risk can be stratified using a limited number of patient and operative characteristics.
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Affiliation(s)
- Madalyn G Peters
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Korb ML, Huh WK, Boone JD, Warram JM, Chung TK, de Boer E, Bland KI, Rosenthal EL. Laparoscopic Fluorescent Visualization of the Ureter With Intravenous IRDye800CW. J Minim Invasive Gynecol 2015; 22:799-806. [PMID: 25796218 DOI: 10.1016/j.jmig.2015.03.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/08/2015] [Accepted: 03/12/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Ureter injury is a serious complication of laparoscopic surgery. Current strategies to identify the ureters, such as placement of a ureteral stent, carry additional risks for patients. We hypothesize that the systemically injected near-infrared (NIR) dye IRDye800CW-CA can be used to visualize ureters intraoperatively. METHODS Adult female mixed-breed pigs weighing 24 to 41 kg (n = 2 per dose) were given a 30, 60, or 120 μg/kg systemic injection of IRDye800CW-CA. Using the Food and Drug Administration-cleared Pinpoint laparoscopic NIR system, images of the ureter and bladder were captured every 10 minutes for 60 minutes after injection. To determine the biodistribution of the dye, tissues were collected for ex vivo analysis with the Pearl Impulse system. ImageJ software was used to quantify fluorescence signal and signal-to-background ratio (SBR) for the intraoperative images. RESULTS The ureter was identified in all pigs at each dose, with peak intensity reached by 30 minutes and remaining elevated throughout the duration of imaging (60 minutes). The 60 μg/kg dose was determined to be optimal for differentiating ureters according to absolute fluorescence (>60 counts/pixel) and SBR (3.1). Urine fluorescence was inversely related to plasma fluorescence (R(2) = -0.82). Ex vivo imaging of kidney, ureter, bladder, and abdominal wall tissues revealed low fluorescence. CONCLUSION Systemic administration of IRDye800CW-CA shows promise in providing ureteral identification with high specificity during laparoscopic surgery. The low dose required, rapid time to visualization, and absence of invasive ureteral instrumentation inherent to this technique may reduce complications related to pelvic surgery.
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Affiliation(s)
- Melissa L Korb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Warner K Huh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Jonathan D Boone
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.
| | - Jason M Warram
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas K Chung
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Esther de Boer
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kirby I Bland
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Eben L Rosenthal
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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How do risk factors for mortality and overall complication rates following laparoscopic and open colectomy differ between inpatient and post-discharge phases of care? A retrospective cohort study from NSQIP. Surg Endosc 2014; 28:3392-400. [PMID: 24928234 DOI: 10.1007/s00464-014-3609-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/08/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Risk factors for complications differ between laparoscopic (LC) and open colectomy (OC) patients, given the selection bias between these groups. How risk factors for these outcomes differ between inpatient and post-discharge phases of care requires further study. METHODS A retrospective cohort study (2005-2010) using NSQIP data was performed comparing OC and LC patients. Multivariable logistic regression was used to compare covariates associated with mortality and overall complication rates both before and after hospital discharge. RESULTS Patients in the LC cohort were younger (64.2 vs. 62.5 years; P < 0.0001) with a lower incidence of comorbidities. OC was associated with a higher incidence of mortality compared to LC among inpatients (3.3 vs. 0.61%, P < 0.0001) and following discharge (0.88 vs. 0.29%, P < 0.0001). OC also demonstrated a higher incidence of overall complication rates for both inpatients (22.32 vs. 9.36%, P < 0.0001) and following discharge (8.83 vs. 7.24%, P < 0.0001). Risk factors (P < 0.05) for mortality following LC included age and emergency procedures for inpatients; pre-operative SIRS was associated with mortality occurring after discharge. For the OC cohort, risk for mortality was increased with smoking and contaminated/dirty wounds for inpatients; pre-operative weight loss was associated with death following discharge. Factors associated with increased risk of morbidity following LC included smoking history for inpatients and pre-operative steroid therapy following discharge. Following OC, morbidity was strongly associated with ASA scores for inpatients; pre-operative steroid therapy was a risk factor following discharge. Obesity was strongly associated with non-mortal complications in both cohorts following discharge. CONCLUSIONS (1) LC is associated with a lower incidence of post-operative mortality and complications. (2) Risk factors associated with adverse post-operative outcomes change during the post-operative period; surveillance for these outcomes should be tailored by operative technique and phase of post-operative care (3) Obesity is an underappreciated risk for complications following discharge for both LC and OC.
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Wilson MZ, Hollenbeak CS, Stewart DB. Laparoscopic colectomy is associated with a lower incidence of postoperative complications than open colectomy: a propensity score-matched cohort analysis. Colorectal Dis 2014; 16:382-9. [PMID: 24373345 DOI: 10.1111/codi.12537] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/20/2013] [Indexed: 12/16/2022]
Abstract
AIM Elective laparoscopic colectomy (LC) has been shown to provide short-term results comparable with open colectomy (OC), but there is potential selection bias whereby LC patients may be healthier and therefore more likely to have a superior outcome. The aim of this study was to compare the incidence of postoperative complications between matched laparoscopic and open colectomy cohorts, while controlling for differences in comorbidity. METHOD A retrospective cohort study (2005-2010) using National Surgical Quality Improvement Program data was performed, identifying laparoscopic and open partial colectomy patients through common procedural terminology codes. Patient having rectal resection were excluded. The cohorts were matched 1:1 on a propensity score to control for observable selection bias due to patient characteristics, comparing overall complication rates, length of hospital stay (LOS), the incidence of superficial (S-SSI) surgical site infection, urinary tract infection (UTI) and deep-venous thrombosis (DVT). RESULTS We analysed 37 249 patients. After propensity score matching the LC group had a significantly lower overall incidence of postoperative complications (29.1 vs 21.2%; P < 0.0001), S-SSI (9.0 vs 5.9%; P = 0.003) and DVT (1.2 vs 0.3%; P = 0.001). The LC group had a shorter LOS (8.7 vs 6.4 days; P < 0.0001), while mortality was comparable between the two groups (4.0 vs 4.1%; P = 0.578). CONCLUSION LC is associated with a lower incidence of S-SSI and DVT than OC. Previously suggested advantages for laparoscopy, such as shorter length of stay and overall rate of complications, were observed even after controlling for differences in comorbidity.
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Affiliation(s)
- M Z Wilson
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
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Lorenzon L, La Torre M, Ziparo V, Montebelli F, Mercantini P, Balducci G, Ferri M. Evidence based medicine and surgical approaches for colon cancer: Evidences, benefits and limitations of the laparoscopic vs open resection. World J Gastroenterol 2014; 20:3680-3692. [PMID: 24707154 PMCID: PMC3974538 DOI: 10.3748/wjg.v20.i13.3680] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/26/2013] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To report a meta-analysis of the studies that compared the laparoscopic with the open approach for colon cancer resection.
METHODS: Forty-seven manuscripts were reviewed, 33 of which employed for meta-analysis according to the PRISMA guidelines. The results were differentiated according to the study design (prospective randomized trials vs case-control series) and according to the tumor’s location. Outcome measures included: (1) short-term results (operating times, blood losses, bowel function recovery, post-operative pain, return to the oral intake, complications and hospital stay); (2) oncological adequateness (number of nodes harvested in the surgical specimens); and (3) long-term results (including the survivals’ rates and incidence of incisional hernias) and (4) costs.
RESULTS: Meta-analysis of trials provided evidences in support of the laparoscopic procedures for a several short-term outcomes including: a lower blood loss, an earlier recovery of the bowel function, an earlier return to the oral intake, a shorter hospital stay and a lower morbidity rate. Opposite the operating time has been confirmed shorter in open surgery. The same trend has been reported investigating case-control series and cancer by sites, even though there are some concerns regarding the power of the studies in this latter field due to the small number of trials and the small sample of patients enrolled. The two approaches were comparable regarding the mean number of nodes harvested and long-term results, even though these variables were documented reviewing the literature but were not computable for meta-analysis. The analysis of the costs documented lower costs for the open surgery, however just few studies investigated the incidence of post-operative hernias.
CONCLUSION: Laparoscopy is superior for the majority of short-term results. Future studies should better differentiate these approaches on the basis of tumors’ location and the post-operative hernias.
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Søndenaa K, Quirke P, Hohenberger W, Sugihara K, Kobayashi H, Kessler H, Brown G, Tudyka V, D'Hoore A, Kennedy RH, West NP, Kim SH, Heald R, Storli KE, Nesbakken A, Moran B. The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery : proceedings of a consensus conference. Int J Colorectal Dis 2014; 29:419-28. [PMID: 24477788 DOI: 10.1007/s00384-013-1818-2] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors. METHOD There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction. RESULT The oncological rationale for CME and various technical aspects of the surgical management will be explored. CONCLUSION The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.
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Affiliation(s)
- K Søndenaa
- Department of Surgery, Haraldsplass Deaconess Hospital, POB 6165, 5892, Bergen, Norway,
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Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach. Surg Endosc 2014; 28:1940-8. [PMID: 24515259 DOI: 10.1007/s00464-014-3419-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 01/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. METHODS Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. RESULTS Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). CONCLUSIONS LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
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Soma G, Greenblatt DY, Nelson MT, Rajamanickam V, Havlena J, Fernandes-Taylor S, Greenberg CC, Kent KC. Early graft failure after infrainguinal arterial bypass. Surgery 2014; 155:300-10. [DOI: 10.1016/j.surg.2013.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
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[Effects of surgical simulation on the implementation of laparoscopic colorectal procedures]. Cir Esp 2013; 92:100-6. [PMID: 24060161 DOI: 10.1016/j.ciresp.2013.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 03/27/2013] [Accepted: 03/27/2013] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning. OBJECTIVE We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation. MATERIAL AND METHODS Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12h in animal models, and 4h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work. RESULTS Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was>10 cases/month in 19%, and<5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach. CONCLUSIONS Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.
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Burns EM, Mamidanna R, Currie A, Bottle A, Aylin P, Darzi A, Faiz OD. The role of caseload in determining outcome following laparoscopic colorectal cancer resection: an observational study. Surg Endosc 2013; 28:134-42. [PMID: 24052341 DOI: 10.1007/s00464-013-3139-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/22/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection. METHODS All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission. RESULTS There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002-2003 and 2007-2008. In 2002-2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007-2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85-0.91), p < 0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04-1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04-1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission. CONCLUSION Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome. WHAT'S NEW IN THIS MANUSCRIPT This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.
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Affiliation(s)
- Elaine M Burns
- Department of Surgery, St Mary's Hospital, Imperial College, Praed Street, London, W2 1NY, UK,
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Hospital readmissions and emergency department visits following laparoscopic and open colon resection for cancer. Dis Colon Rectum 2013; 56:1053-61. [PMID: 23929014 DOI: 10.1097/dcr.0b013e318293eabc] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic colectomy for the treatment of colon cancer has been widely adopted in community practice, in part, because of shorter hospitalizations. The benefits of a shorter hospital stay are only realized if readmissions and emergency department visits, collectively termed revisits, do not increase after discharge. We conducted a population-based analysis to determine whether hospitals with higher laparoscopic colectomy rates have higher revisit rates. OBJECTIVE The aim of this study was to determine whether hospital utilization after discharge is increased for patients undergoing laparoscopic colectomy for cancer. DESIGN This is a retrospective cohort study. SETTINGS Data were gathered from the Healthcare Cost and Utilization Project's inpatient and emergency department databases for California. These databases include data from all nonfederal hospitals in the State of California. PATIENTS Patients who underwent elective colectomy for cancer from 2008 to 2009 were included. INTERVENTIONS The primary intervention was elective colectomy with the use of the open or laparoscopic approach. MAIN OUTCOME MEASURES The correlation between hospital laparoscopy rates and hospital readmission rates, emergency department visit rates, and revisit rates was calculated. RESULTS Overall, 6760 patients were treated at 176 hospitals. For every 100 patients discharged, there were 14.0 readmissions and 9.2 emergency department encounters. At the hospital level, laparoscopy rates varied considerably (median = 45.7%, range = 2.2%-88.9%), as did the risk-standardized readmission (12.1%, 8.6%-16.5%), emergency department encounter (7.8%, 4.1%-18.0%), and revisit rates (17.9%, 13.0%-26.4%). A hospital's laparoscopy rate was not significantly correlated with its risk-standardized readmission (weighted correlation coefficient = 0.05, p = 0.50), emergency department encounter (-0.11, p = 0.16), or revisit (-0.03, p = 0.70) rates. LIMITATIONS There are inherent limitations when using administrative data. CONCLUSIONS Hospitals where a greater proportion of colon resections for cancer are approached laparoscopically do not have higher 30-day, risk-standardized readmission, emergency department encounter, or revisit rates.
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Kvarnström A, Swartling T, Kurlberg G, Bengtson JP, Bengtsson A. Pro-inflammatory Cytokine Release in Rectal Surgery: Comparison Between Laparoscopic and Open Surgical Techniques. Arch Immunol Ther Exp (Warsz) 2013; 61:407-11. [DOI: 10.1007/s00005-013-0239-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 07/23/2013] [Indexed: 10/26/2022]
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Malafaia O, Montagnini AL, Luchese A, Accetta AC, Zilberstein B, Malheiros CA, Jacob CE, Quireze-Junior C, Bresciani CJC, Kruel CDP, Cecconello I, Sad EF, Ohana JAL, Aguilar-Nascimento JED, Manso JEF, Ribas-Filho JM, Santo MA, Andreollo NA, Torres OJM, Herman P, Cuenca RM, Sallum RAA, Bernardo WM. Thromboembolism prevention in surgery of digestive cancer. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 25:216-23. [PMID: 23411918 DOI: 10.1590/s0102-67202012000400002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 11/10/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. AIM To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. METHODS The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. RESULTS A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. CONCLUSION It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.
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Affiliation(s)
- Osvaldo Malafaia
- Colégio Brasileiro de Cirurgia Digestiva, São Paulo, SP, Brazil.
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Wagner M, Zappa M, Maggiori L, Bretagnol F, Vilgrain V, Panis Y. Can postoperative complications be predicted by a routine CT scan on day 5? A study of 78 laparoscopic colorectal resections. Tech Coloproctol 2013; 18:239-45. [PMID: 23860629 DOI: 10.1007/s10151-013-1047-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative computed tomography (CT) scan patterns after colorectal resection are difficult to analyze for both clinicians and radiologists. This study aimed to assess the role of single CT scan on postoperative day 5 in predicting postoperative morbidity. METHODS From October 2007 to August 2009, 78 patients undergoing laparoscopic colorectal resection were enrolled in a research study involving a routine contrast-enhanced multi-detector CT scan on postoperative day 5. Two groups were defined: patients with intra-abdominal postoperative morbidity requiring specific management, i.e., surgical or radiological procedure, and/or antibiotic therapy ("complications" group), and patients with uneventful postoperative outcome ("uneventful" group). CT findings were compared between the two groups with Fisher's exact test or chi-square test. RESULTS Postoperative abdominal complications occurred in 16 patients (21 %). Of the CT findings on day 5, pneumonia, pulmonary embolism, portal or mesenteric thrombosis, operative area fat infiltration, peritoneal effusion, pneumoperitoneum, intra-abdominal collection, parietal inflammation or collection, and subcutaneous emphysema were observed in both groups without any significant difference. Only small bowel distension [25 % (4/16) in the "complications" group vs. 5 % (3/62) in the "uneventful" group; p = 0.029] and pleural effusion [81 % (13/16) vs. 48 % (30/62); p = 0.024, respectively] were observed significantly more often in the "complications" group. CONCLUSIONS This study suggested that abdominal complications cannot be predicted by a CT scan on day 5 after laparoscopic colorectal resection. Thus, it cannot be recommended for routine use.
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Affiliation(s)
- M Wagner
- Department of Radiology, Beaujon Hospital, Universitary Hospitals Paris Nord Val de Seine, Beaujon, Clichy Cedex, France
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Successful and safe introduction of laparoscopic colorectal cancer surgery in Dutch hospitals. Ann Surg 2013; 257:916-21. [PMID: 22735713 DOI: 10.1097/sla.0b013e31825d0f37] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the safety of laparoscopic colorectal cancer resections in a nationwide population-based study. BACKGROUND Although laparoscopic techniques are increasingly used in colorectal cancer surgery, little is known on results outside trials. With the fast introduction of laparoscopic resection (LR), questions were raised about safety. METHODS Of all patients who underwent an elective colorectal cancer resection in 2010 in the Netherlands, 93% were included in the Dutch Surgical Colorectal Audit. Short-term outcome after LR, open resection (OR), and converted LR were compared in a generalized linear mixed model. We further explored hospital differences in LR and conversion rates. RESULTS A total of 7350 patients, treated in 90 hospitals, were included. LR rate was 41% with a conversion rate of 15%. After adjustment for differences in case-mix, LR was associated with a lower risk of mortality (odds ratio 0.63, P < 0.01), major morbidity (odds ratio 0.72, P < 0.01), any complications (odds ratio 0.74, P < 0.01), hospital stay more than 14 days (odds ratio 0.71, P < 0.01), and irradical resections (odds ratio 0.68, P < 0.01), compared to OR. Outcome after conversion was similar to OR (P > 0.05). A large variation in LR and conversion rates among hospitals was found; however, the difference in outcome associated with operative techniques was not influenced by hospital of treatment. CONCLUSIONS Use of laparoscopic techniques in colorectal cancer surgery in the Netherlands is safe and results are better in short-term outcome than open surgery, irrespective of the hospital of treatment. Outcome after conversion was similar to OR.
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Abstract
BACKGROUND Robotic-assisted surgery has become increasingly common; however, it is unclear if its use for colectomy improves in-hospital outcomes compared with the laparoscopic approach. OBJECTIVE The aim of the study is to compare in-hospital outcomes and costs between patients undergoing robotic or laparoscopic colectomy. DESIGN This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS: All adult patients who underwent an elective robotic or laparoscopic colectomy in hospitals performing both procedures (N = 2583 representing an estimated 12,732 procedures) were included. MAIN OUTCOME MEASURES Outcomes included intraoperative and postoperative complications, length of stay, and direct costs of care. Regression models were used to compare these outcomes between procedural approaches while controlling for baseline differences in patient characteristics. RESULTS Overall, 6.1% of patients underwent a robotic procedure. Factors associated with robotic-assisted colectomy included younger age, benign diagnoses, and treatment at a lower-volume center. Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35-2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54-1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different. LIMITATIONS A limitation of this study is the potential miscoding of robotic cases in administrative data. CONCLUSIONS Robotic-assisted colectomy significantly increases the costs of care without providing clear reductions in overall morbidity or length of stay. As the use of robotic technology in colon surgery continues to evolve, critical appraisal of the benefits offered in comparison with the resources consumed is required.
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Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP. World J Surg 2013; 36:2488-96. [PMID: 22736343 DOI: 10.1007/s00268-012-1694-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection. METHODS Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses. RESULTS A total of 341 laparoscopic (9.6 %) and 3211 (90.4 %) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p < 0.001) and shorter total (p = 0.013) and postoperative (p = 0.004) hospital stays, but it did not affect the need for intraoperative blood transfusion (p = 0.488), the 30-day reoperation rates (p = 0.969), or mortality (p = 0.417). After adjusted propensity score analysis, postoperative morbidity (p = 0.833) and mortality (p = 0.568) were comparable in patients undergoing laparoscopic and open surgery. CONCLUSIONS On a national scale, laparoscopic emergent colon resections are being performed in a small number of patients, who have favorable co-morbidity characteristics and improved postoperative outcomes. Laparoscopic emergent colon resection with primary anastomosis has postoperative morbidity and mortality rates comparable to those seen with the open approach, and it reduces the total and postoperative length of hospital stay.
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Hasegawa F, Kawamura YJ, Sasaki J, Tsujinaka S, Konishi F. Oncological 3-port laparoscopic colectomy by 1 surgeon and 1 camera operator: a preliminary report. Surg Laparosc Endosc Percutan Tech 2013; 23:176-179. [PMID: 23579514 DOI: 10.1097/sle.0b013e31828a0bd7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This retrospective study analyzed the short-term outcomes of oncological reduced-port laparoscopic colectomy (RPLC) using 3 ports performed by 1 surgeon and 1 camera operator. Patients who underwent laparoscopic colectomy for colorectal carcinoma in 2010 and 2011 were divided into 2 groups: the CLC group, which included 62 patients who underwent a conventional laparoscopic colectomy and the RPLC group, which included 28 patients who underwent reduced-port laparoscopic colectomy, respectively. There were no significant differences between the groups with regard to TNM stage, estimated blood loss, complications, conversion rate, pain score, the length of postoperative stay, or the number of harvested lymph nodes. However, the prevalence of right-side colectomy was higher and the operative time was significantly shorter in the RPLC group. RPLC was technically feasible, providing that the appropriate patients were selected. Therefore, even though its surgical benefit might be subtle, we believe that RPLC definitively contributes to the reduction of equipment and manpower costs and will be considered as a standard procedure in the near future.
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Affiliation(s)
- Fumi Hasegawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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