501
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A standardized technique for laparoscopic rectal resection. J Gastrointest Surg 2009; 13:2059-63. [PMID: 19756876 DOI: 10.1007/s11605-009-1033-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 08/26/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic rectal resection (LRR) has not gained the same acceptance as laparoscopic segmental colonic resection because of technical challenges, increased operating time and costs, and concerns about the oncological outcome. DISCUSSION One way to overcome these challenges is by standardizing the laparoscopic technique in the same way as has been done with the open rectal cancer surgery. We have established a standardized, stepwise laparoscopic procedure for rectal resections that enhances the transformation of laparoscopic skills, identifies indications for conversion early in the operation, and makes the operation predictable and reproducible for the whole surgical team. CONCLUSION We believe this saves time in the operating room and builds up laparoscopic team expertise.
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502
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Laparoscopically assisted vs. open elective colonic and rectal resection: a comparison of outcomes in English National Health Service Trusts between 1996 and 2006. Dis Colon Rectum 2009; 52:1695-704. [PMID: 19966600 DOI: 10.1007/dcr.0b013e3181b55254] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to compare outcomes after elective laparoscopic and conventional colorectal surgery over a ten-year period using data from the English National Health Service Hospital Episode Statistics database. METHODS All elective colonic and rectal resections carried out in English Trusts between 1996 and 2006 were included. Univariate and multivariate analyses were used to compare 30 and 365-day mortality rates, 28-day readmission rates, and length of stay between laparoscopic and open surgery. RESULTS Between the study dates 3,709 of 192,620 (1.9%) elective colonic and rectal resections were classified as laparoscopically assisted procedures. The 30-day and 365-day mortality rates were lower after laparoscopic resection than after open surgery (P < 0.05). After correction for age, gender, diagnosis, operation type, comorbidity, and social deprivation, laparoscopic surgery was a strong determinant of reduced 30-day (odds ratio, 0.57; 95% confidence interval, 0.44-0.74; P < 0.001) and one-year (odds ratio, 0.53; 95% confidence interval, 0.42-0.67; P < 0.001) mortality. Similarly, multivariate analysis confirmed that laparoscopic surgery was independently associated with reduced hospital stay (P < 0.001). Patients who received rectal procedures for malignancy, however, were more likely to be readmitted if laparoscopy rather than by a traditional method was used (11.9% vs. 9.1%, P = 0.003). CONCLUSION In the present study, patients selected for laparoscopic colorectal surgery were associated with reduced postoperative mortality when compared with those undergoing the conventional technique. This finding merits further investigation.
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503
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Birch DW, Bonjer HJ, Crossley C, Burnett G, de Gara C, Gomes A, Hagen J, Maciver AG, Mercer CD, Panton ON, Schlachta CM, Smith AJ, Warnock GL. Canadian consensus conference on the development of training and practice standards in advanced minimally invasive surgery: Edmonton, Alta., Jun. 1, 2007. Can J Surg 2009; 52:321-327. [PMID: 19680520 PMCID: PMC2724806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
Despite the complexities of minimally invasive surgery (MIS), a Canadian approach to training surgeons in this field does not exist. Whereas a limited number of surgeons are fellowship-trained in the specialty, guidelines are still clearly needed to implement advanced MIS. Leaders in the field of gastrointestinal surgery and MIS attended a consensus conference where they proposed a comprehensive mentoring program that may evolve into a framework for a national mentoring and training system. Leadership and commitment from national experts to define the most appropriate template for introducing new surgical techniques into practice is required. This national framework should also provide flexibility for truly novel procedures such as natural orifice translumenal endoscopic surgery.
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Affiliation(s)
- Daniel W. Birch
- Centre for the Advancement of Minimally Invasive Surgery (CAMIS), the
| | - H. Jaap Bonjer
- Department of Surgery, Dalhousie University, Halifax, NS
| | | | - Gayle Burnett
- Centre for the Advancement of Minimally Invasive Surgery (CAMIS), the
| | - Chris de Gara
- Department of Surgical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, the
| | | | - John Hagen
- Humber River Regional Hospital, Toronto, Ont., the
| | - Angus G. Maciver
- Huron Perth Health Association, Stratford, Ont., the
- University of Western Ontario, London, and the
| | - C. Dale Mercer
- Departments of Surgery, Queen’s University, Kingston, Ont
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504
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Braunstein V, Kirchhoff C, Ockert B, Sprecher CM, Korner M, Mutschler W, Wiedemann E, Biberthaler P. Use of the fulcrum axis improves the accuracy of true anteroposterior radiographs of the shoulder. ACTA ACUST UNITED AC 2009; 91:1049-53. [DOI: 10.1302/0301-620x.91b8.22567] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 100 patients the fulcrum axis which is the line connecting the anterior tip of the coracoid and the posterolateral angle of the acromion, was used to position true anteroposterior radiographs of the shoulder. This method was then compared with the conventional radiological technique in a further 100 patients. Three orthopaedic surgeons counted the number of images without overlap between the humeral head and glenoid and calculated the amount of the glenoid surface visible in each radiograph. The analysis was repeated for intraobserver reliability. The learning curves of both techniques were studied. The amount of free visible glenoid space was significantly higher using the fulcrum-axis method (64 vs 31) and the comparable glenoid size increased significantly (8.56 vs 6.47). Thus the accuracy of the anteroposterior radiographs of the shoulder is impaired by using this technique. The intra and interobserver reliability showed a high consistency. No learning curve was observed for either technique.
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Affiliation(s)
| | - C. Kirchhoff
- Department of Orthopaedic Sports Surgery Klinikum Rechts der Isar, Technische Universitaet, Ismaningerstrasse 22, 81675 Munich, Germany
| | - B. Ockert
- Department of Traumatology and Orthopaedic Surgery
| | - C. M. Sprecher
- AO Research Institute AO Foundation, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - M. Korner
- Department of Clinical Radiology Ludwig-Maximilians-University, Nussbaumstrasse 20, 80336 Munich, Germany
| | - W. Mutschler
- Department of Traumatology and Orthopaedic Surgery
| | - E. Wiedemann
- OCM-Clinic, Steinerstrasse 6, 81369 Munich, Germany
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505
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Conversion from laparoscopic to open colonic cancer resection - associated factors and their influence on long-term oncological outcome. Eur J Surg Oncol 2009; 35:1273-9. [PMID: 19615848 DOI: 10.1016/j.ejso.2009.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 06/08/2009] [Accepted: 06/11/2009] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Comparisons of open and laparoscopic colon cancer resection have shown that laparoscopy offers an oncologically safe option. However, there are no data on long-term influence of converted resection, despite conversion rates of up to 30% and the general observation that short-term outcome is significantly worsened. The aim was to compare the long-term results of primary open resection (OR), purely laparoscopic resection (LR-p) and converted resection (LR-c). METHODS In a prospective study at 282 German hospitals demographic, tumor- and treatment-related data and disease-free survival were compared in the three groups. RESULTS 8015 of 8307 patients with OR, 280 of 290 patients with LR-p and 55 of 56 patients with LR-c were followed for 39.5 months (median). Overall, no statistically significant differences were seen for five-year DFS (74.8%, 81.3% and 65.6%). However, for patients in stage II with conversion, the five-year DFS was significantly poorer (43.3%) than for OR (80.5%; p=0.003) and LR-p patients (92.5%; p=0.001). For stages I and III no differences were observed. CONCLUSION Conversion of laparoscopic colon cancer resection worsens DFS in locally advanced stage II carcinoma. There is a need to reduce the conversion rate by adequate patient selection for laparoscopic resection by experienced surgeons.
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506
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Chikkappa MG, Jagger S, Griffith JP, Ausobsky JR, Steward MA, Davies JB. In-house colorectal laparoscopic preceptorship: a model for changing a unit's practice safely and efficiently. Int J Colorectal Dis 2009; 24:771-6. [PMID: 19221762 DOI: 10.1007/s00384-009-0675-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been steady increase in demand for laparoscopic colonic resection as benefits are manifold compared to open and include smaller incisions, less pain, quicker recovery and convalescence, reduced morbidity and reduced analgesic demands. We devised a preceptorship programme with the aim of all four coloproctologists in our unit becoming proficient colorectal laparoscopic surgeons over a period of 12 months. METHOD The surgeon in the unit with significant experience of laparoscopic colorectal surgery acted as a preceptor to the remaining three. A prospective database was set up to allow analysis of the impact of the preceptorship on the units' elective practice and outcomes from January 2006. RESULTS Results were analysed 106 cases to assess the success of this novel method and were more than encouraging. During this period, 57 laparoscopic resections were performed compared 49 open resections. The proportion of patients undergoing laparoscopic resection had risen from 20% to 80% (p = 0.000). This was associated with a significant drop in post-operative stay from 14 to 4 days (p = 0.000). Analysis of patient demographics, pathology and type of resection found there to be no significant difference between the open and laparoscopic groups. The conversion rate was acceptably low (10.5%) and there were no re-admissions. CONCLUSIONS For hospitals with the facilities and an appropriately experienced preceptor, we offer this as a patient-safe, cost-neutral method of significantly increasing a units' laparoscopic practice over a relatively short period of time.
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507
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Inomata M, Yasuda K, Shiraishi N, Kitano S. Clinical evidences of laparoscopic versus open surgery for colorectal cancer. Jpn J Clin Oncol 2009; 39:471-7. [PMID: 19556338 DOI: 10.1093/jjco/hyp063] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Laparoscopic surgery has widely spread in the treatment of colorectal cancer. In Japan, a nation-wide survey has shown that a rate of advanced colorectal cancer has increased gradually and reached 65% of the total cases for colorectal cancer in 2007. For colon cancer, many randomized controlled trials regarding short-term outcome demonstrate that laparoscopic surgery is feasible, safe and has many benefits including reduction in a peri-operative mortality. In terms of long-term outcome, four randomized controlled trials insist that there are no differences in both laparoscopic and open surgeries. However, there are still more important issues including long-term oncological outcome for advanced colon cancer, cost effectiveness and the impact on quality of life of patients. Meanwhile, for rectal cancer, a controversy persists with regard to the appropriateness of laparoscopic surgery because of concerns over the safety of the procedure and a necessity of lateral lymph node dissection for lower rectal cancer. At present, laparoscopic surgery is acceptable for Stage I colon cancer, whereas there are controversies for Stage II/III colon cancer and each staged rectal cancer because of inadequate clinical evidences. Whether laparoscopic surgery further spreads to be applied for colorectal cancer or not, it would be confirmed by Japanese large-scale phase III trial (JCOG0404) estimating oncological outcome for Stage II/III colon cancer and a Phase II trial estimating the feasibility for Stage 0/I rectal cancer in near future.
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Affiliation(s)
- Masafumi Inomata
- Department of Gastroenterological Surgery, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita 879-5593, Japan.
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508
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Shabbir A, Roslani AC, Wong KS, Tsang CBS, Wong HB, Cheong WK. Is laparoscopic colectomy as cost beneficial as open colectomy? ANZ J Surg 2009; 79:265-70. [PMID: 19432712 DOI: 10.1111/j.1445-2197.2009.04857.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Laparoscopic colectomy has yet to gain widespread acceptance in cost-conscious health-care institutions. The aim of the present study was to define the cost-benefit relationship of laparoscopic versus open colectomy. METHODS Thirty-two consecutive patients undergoing elective laparoscopic colectomy (LC) by a single colorectal surgeon between August 2004 and September 2005 were reviewed. Cases were matched with a historical cohort undergoing elective open colectomy (OC) between June 2003 and July 2004. Demography, perioperative data, histopathology and cost were compared. RESULTS Both groups had similar demographics. Most resections (90.6%) were for cancer. Operative time was significantly longer for LC compared to OC (180 min vs 110 min, P < 0.001). Four patients (12.5%) in the LC group required conversion. LC patients, however, had lower median pain scores (3, 2 and 1 vs 6, 4 and 2 at 24, 48 and 72 h postoperatively, P < 0.001), faster resolution of ileus (3 vs 4 days, P < 0.001) and earlier discharge (6 vs 9 days, P < 0.001) compared to the OC group. As a result, overall hospital cost for both procedures was not significantly different (US$7943 vs US$7253, P = 0.41). CONCLUSION Laparoscopic colectomy is as cost-beneficial in the short term as open colectomy.
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Affiliation(s)
- Asim Shabbir
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
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509
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Williams GL, Sagar PM, McAllister I, Gonsalves S. The laparoscopic colorectal fellowships are popular, educational and produce competent laparoscopic surgeons. Colorectal Dis 2009; 11:519-21. [PMID: 19341403 DOI: 10.1111/j.1463-1318.2009.01845.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- G L Williams
- The John Goligher Colorectal Unit, The General Infirmary at Leeds, Leeds, UK
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510
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Jones OM, Stevenson ARL, Stitz RW, Lumley JW. Preservation of sexual and bladder function after laparoscopic rectal surgery. Colorectal Dis 2009; 11:489-95. [PMID: 18637928 DOI: 10.1111/j.1463-1318.2008.01642.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery. METHOD This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum. RESULTS A total of 101 males were identified (median age 62 years: range 20-90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients. CONCLUSIONS The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons''learning curve'.
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Affiliation(s)
- O M Jones
- Royal Brisbane Hospital, Herston, Australia.
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511
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Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009; 249:719-24. [PMID: 19387334 DOI: 10.1097/sla.0b013e3181a38e59] [Citation(s) in RCA: 335] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.
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512
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Li JCM, Hon SSF, Ng SSM, Lee JFY, Yiu RYC, Leung KL. The learning curve for laparoscopic colectomy: experience of a surgical fellow in an university colorectal unit. Surg Endosc 2009; 23:1603-8. [PMID: 19452217 DOI: 10.1007/s00464-009-0497-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 04/04/2009] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aimed to evaluate the learning curve for laparoscopic colectomy of a surgical fellow in an university colorectal unit using a structured training protocol. METHODS This study analyzed the data from 100 consecutive patients who had laparoscopic colectomy performed by a surgical fellow between 11/2004 and 12/2007. The structured training protocol required the fellow to assist more than 40 laparoscopic colectomies before embarking on his first case. Rectosigmoidectomy was prioritized during the initial experience. Operative times were analyzed to represent the learning curve. Other outcome data including conversion and operative outcome were also evaluated. RESULTS The following procedures were performed: 49 rectosigmoidectomies, 38 right colon resections, and 13 other resections. Median operative time was 150 min, and conversion rate was 1%. Overall postoperative morbidity rate was 28% (major morbidity 3%). Three patients required early reoperation. There was no operative death. Median hospital stay was 8 days. Operative times reached their lowest point at period of cases 45-50, and remained relatively stable afterwards. Comparing the first 50 and second 50 cases, the only difference observed was more frequent presence of a supervisor in the theater in the first 50 cases (74% versus 52%, p = 0.02), while the other parameters including types of procedures, postoperative recovery, hospital stay, and morbidity rate were not different. CONCLUSIONS Our results indicated that laparoscopic colectomy training can be safely performed under a structured protocol. The surgeon can perform laparoscopic colectomies more independently after 50 cases, without jeopardizing the clinical outcome.
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Affiliation(s)
- Jimmy C M Li
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
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513
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Kitano S, Inomata M. Is laparoscopic surgery acceptable for advanced colon cancer? Cancer Sci 2009; 100:567-71. [PMID: 19154419 PMCID: PMC11159689 DOI: 10.1111/j.1349-7006.2008.01074.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 11/23/2008] [Accepted: 11/28/2008] [Indexed: 12/16/2022] Open
Abstract
Laparoscopic surgery is widespread in the treatment of colorectal cancer. In Japan, a nationwide survey has shown that the rate of advanced colorectal cancer has increased gradually to 65% of total laparoscopic surgeries in 2007. Many randomized controlled trials have demonstrated that in the short term, laparoscopic surgery is feasible, safe, and has many benefits, including reduction of peri-operative mortality. In terms of long-term outcomes, four randomized controlled trials suggest that there are no differences in laparosupic and open surgery for colon cancer. However, important issues, including long-term oncological outcome, cost effectiveness, and the impact on the quality of life of patients, should be addressed in well-designed large-scale trials. In Japan, a retrospective multicenter study has demonstrated that the short-term outcomes of laparoscopic surgery are beneficial, and the long-term outcomes are the same as for open surgery. In 2004, a prospective large-scale randomized controlled trial (JCOG0404) to compare laparoscopic surgery with open surgery was started to evaluate oncological outcomes for advanced colon cancer. This trial is supported in part by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health, Labour, and Welfare. In the present study, laparoscopic surgery is found to be acceptable for stage I disease of colon cancer, whereas it is controversial for stage II/III disease because of inadequate clinical evidence. Whether laparoscopic surgery is acceptable for advanced colon cancer or not should be confirmed by the Japanese large-scale prospective randomized controlled trial (JCOG0404) in the near future.
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Affiliation(s)
- Seigo Kitano
- Department of Gastroenterological Surgery, Oita University Faculty of Medicine.
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514
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Impact of Obesity on Laparoscopic-assisted Left Colectomy in Different Stages of the Learning Curve. Surg Laparosc Endosc Percutan Tech 2009; 19:114-7. [DOI: 10.1097/sle.0b013e31819f2035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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515
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Dolay K, Soylu A. Easy sphincterotomy in patients with Billroth II gastrectomy: a new technique. TURKISH JOURNAL OF GASTROENTEROLOGY 2009; 12:185-8. [PMID: 19110666 DOI: 10.1007/s10151-008-0416-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 04/14/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS ERCP and endoscopic sphincterotomy in patients with Billroth II gastrectomy are technically more difficult due to the reversed anatomy. We developed a new guidewire sphincterotome that includes two 15-mm non-isolated metal parts, one of which is located 12 cm from the distal tip and the other in the proximal end. The aim of this study was to evaluate the feasibility of and outcomes with the new sphincterotome for sphincterotomy in patients with Billroth II gastrectomy. METHODS Between January 2004 and March 2007, 11 patients with Billroth II gastrectomy underwent endoscopic sphincterotomy with the new guidewire sphincterotome. Procedures were initiated by deep cannulation of the bile duct with a standard catheter and guidewire sphincterotome. After cholangiography, the catheter was withdrawn with 0.5 to 1 cm of its tip outside the duodenoscope. The distal non-isolated part of the sphincterotome was placed in the papillary orifice. In order to reach the proper position, the duodenoscope's elevator was moved to the downward position, the up-down dial was turned slightly in the downward direction, and then the duodenoscope was pushed slightly forward. Finally, sphincterotomy was performed in the 6 o'clock direction. RESULTS Sphincterotomy with the new sphincterotome was successfully achieved in all patients without using protective pancreatic stents. Seven patients had common bile duct stones, two pancreatitis, one odditis, and another one persistent bile duct leakage. There were no sphincterotomyrelated complications or death during this study. CONCLUSIONS In this pilot study, endoscopic sphincterotomy with a new guidewire sphincterotome in patients with Billroth II gastrectomy was found to be clinically successful, concise, easy to perform, efficient, and reliable. However, further large comparative studies are needed for a definite conclusion.
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Affiliation(s)
- Kemal Dolay
- Department of General Surgery, Bakirköy Dr. Sadi Konuk Training and Research State Hospital, Istanbul.
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516
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Schwab KE, Dowson HM, Van Dellen J, Marks CG, Rockall TA. The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI. Colorectal Dis 2009; 11:318-22. [PMID: 18573117 DOI: 10.1111/j.1463-1318.2008.01601.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland. METHOD A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide. RESULTS Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding. CONCLUSION Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.
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Affiliation(s)
- K E Schwab
- Department of Colorectal Surgery, The Royal Surrey County Hospital, Guildford, Surrey, UK
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517
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Rottoli M, Bona S, Rosati R, Elmore U, Bianchi PP, Spinelli A, Bartolucci C, Montorsi M. Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival. Ann Surg Oncol 2009; 16:1279-86. [PMID: 19252948 DOI: 10.1245/s10434-009-0398-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 02/05/2009] [Accepted: 02/05/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic rectal resection (LRR) is an oncologically safe procedure. The impact of conversion to open surgery on outcomes has not been fully elucidated. The aim of the study is to compare short- and long-term outcomes of converted (CR) and not converted (NCR) patients undergoing LRR. METHODS Data were drawn from a prospective database of LRR performed between 1999 and 2008. Statistical analysis employed the chi-squared or Wilcoxon test and Kaplan-Meier estimation. RESULTS Of 173 patients undergoing LRR, 26 (15%) required conversion. No differences in age, gender, American Society of Anesthesiologists (ASA) score, and T and N stages were observed between CR and NCR patients. Conversion was associated with higher body mass index (BMI) (27.3 versus 24.9 kg/m(2), P < 0.001) and American Joint Committee on Cancer (AJCC) stage IV (26.9% versus 4.8%, P < 0.001), and resulted in longer operative time (342 versus 285 min, P = 0.006) and increased intraoperative complication rate (31% versus 5%, P < 0.001). No differences were observed in postoperative outcome between CR and NCR patients. After a mean follow-up of 46 and 36 months, 5-year disease-free survival was 55.7% in CR group and 79.2% in NCR group (P = 0.007). After exclusion of stage IV patients from the analysis, 5-year disease-free survival was 71.1% in CR group and 85.3% in NCR group (P = 0.17), while the overall recurrence rate was 26.3% in CR patients and 11.4% in NCR patients (P = 0.07). CONCLUSIONS Our study suggests that conversion to open surgery does not affect postoperative outcome, but could have a negative impact on long-term overall recurrence rate. LRR should be performed by experienced surgeons in selected patients.
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Affiliation(s)
- Matteo Rottoli
- General Surgery III, University of Milan, Istituto Clinico Humanitas IRCCS, Rozzano, Milan, Italy.
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Smith JK, Acheson AG, Simpson JAD, Stewart J, Beckingham IJ, Gornall CB, Williams JP, Robinson MH, Maxwell-Armstrong CA. From small acorns--developing a laparoscopic colorectal surgical service. Ann R Coll Surg Engl 2009; 90:606-11. [PMID: 18831870 DOI: 10.1308/003588408x318110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Randomised controlled trials have shown that laparoscopic colorectal surgery is equal in terms of safety to open surgery. Benefits have been seen for length of stay, blood loss, immune suppression and analgesia requirements. The aim of this study was to assess the safety and feasibility of introducing laparoscopic colorectal surgery to our unit. PATIENTS AND METHODS Prospectively collected cases of all patients undergoing laparoscopic colorectal surgery between July 2003 and July 2007 were reviewed. RESULTS A total of 143 patients (75 males and 68 females) with a mean age of 65.8 years (range, 21-95 years) underwent surgery. Laparoscopic resection for colorectal malignancy was performed in 93 patients (65%). The conversion rate for all cases was 14.7%. Mean operative time was 203 min (range, 100-400 min), with a mean blood loss of 180 ml. The mean number of lymph nodes in malignant cases was 13.8 with clear resection margin in all but one case. The mean postoperative stay was 5.6 days (median, 4 days; range, 2-35 days). UKCCR standard for lymph node retrieval was achieved in 62.6% of cases. There were four postoperative deaths. The overall 30-day morbidity rate was 21.7%. The service is consultant-led with 9.8% of cases performed by senior trainees and 37% of procedures performed by two consultants. CONCLUSIONS Laparoscopic colorectal surgery is technically feasible and safe in our hands. Although operative time is longer, this is counterbalanced by shorter hospital stay. The results from this series support the findings of others and continuing development of this service.
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Affiliation(s)
- J K Smith
- Department of General Surgery, Nottingham University Hospitals, Nottingham, UK.
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519
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Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer. J Gastrointest Surg 2009; 13:275-81. [PMID: 18941844 DOI: 10.1007/s11605-008-0722-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 09/24/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND We attempted to assess the learning curve for laparoscopic resection for rectal cancer. METHOD We included 381 patients who underwent laparoscopic resection for rectal cancer between December 2002 and December 2007. The operative experience was divided into four periods according to numbers of operations and significant changes in main surgical results. RESULTS Operative time decreased significantly after 90 operations. The overall anastomotic leakage rate was 3.7%; 14.6% for the first 50 patients and 5.4% for the following 40 patients. The overall conversion rate was 2.9%, 4-6% during the first and second periods, but decreasing thereafter. The number of harvested lymph nodes and distal resection margin was within an acceptable range during the entire period. For the patients with stage I-III tumors, the local recurrence rate was 4.4% and the overall recurrence rate was 22.9%. The local recurrence rate was 8.9% initially and decreasing to 1.4% after the second period. The cumulative incidence of local recurrence decreased to less than 7% after 120 patients and to less than 5% after 180 cases. CONCLUSION The learning curve for laparoscopic surgery for rectal cancer changed over time. Moreover, the learning curve for oncological safety was longer than that for operative safety.
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520
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East JM, Valentine CSP, Kanchev E, Blake GO. Sentinel lymph node biopsy for breast cancer using methylene blue dye manifests a short learning curve among experienced surgeons: a prospective tabular cumulative sum (CUSUM) analysis. BMC Surg 2009; 9:2. [PMID: 19173714 PMCID: PMC2640353 DOI: 10.1186/1471-2482-9-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 01/27/2009] [Indexed: 02/08/2023] Open
Abstract
Background The benefits of sentinel lymph node biopsy (SLNB) for breast cancer patients with histologically negative axillary nodes, in whom axillary lymph node dissection (ALND) is thereby avoided, are now established. Low false negative rate, certainly with blue dye technique, mostly reflects the established high inherent accuracy of SLNB and low axillary nodal metastatic load (subject to patient selection). SLN identification rate is influenced by volume, injection site and choice of mapping agent, axillary nodal metastatic load, SLN location and skill at axillary dissection. Being more subject to technical failure, SLN identification seems to be a more reasonable variable for learning curve assessment than false negative rate. Methylene blue is as good an SLN mapping agent as Isosulfan blue and is much cheaper. Addition of radio-colloid mapping to blue dye does not achieve a sufficiently higher identification rate to justify the cost. Methylene blue is therefore the agent of choice for SLN mapping in developing countries. The American Society of Breast Surgeons recommends that, for competence, surgeons should perform 20 SLNB but admits that the learning curve with a standardized technique may be "much shorter". One appropriate remedy for this dilemma is to plot individual learning curves. Methods Using methylene blue dye, experienced breast surgeons performed SLNB in selected patients with breast cancer (primary tumor < 5 cm and clinically negative ipsilateral axilla). Intraoperative assessment and completion ALND were performed for standardization on the first 13 of 24 cases. SLN identification was plotted for each surgeon on a tabular cumulative sum (CUSUM) chart with sequential probability ratio test (SPRT) limits based on a target identification rate of 85%. Results The CUSUM plot crossed the SPRT limit line after 8 consecutive, positively identified SLN, signaling achievement of an acceptable level of competence. Conclusion Tabular CUSUM charting, based on a justified choice of parameters, indicates that the learning curve for SLNB using methylene blue dye is completed after 8 consecutive, positively identified SLN. CUSUM charting may be used to plot individual learning curves for trainee surgeons by applying a proxy parameter for failure in the presence of a mentor (such as failed SLN identification within 15 minutes).
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Affiliation(s)
- Jeffrey M East
- Department of Surgery, Cornwall Regional Hospital, Montego Bay, Jamaica.
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521
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Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [PMID: 19160288 DOI: 10.1002/14651858.cd006575] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. OBJECTIVES To determine whether virtual reality training can supplement or replace conventional laparoscopic surgical training (apprenticeship) in surgical trainees with limited or no prior laparoscopic experience. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and grey literature until March 2008. SELECTION CRITERIA We included all randomised clinical trials comparing virtual reality training versus other forms of training including video trainer training, no training, or standard laparoscopic training in surgical trainees with little or no prior laparoscopic experience. We also included trials comparing different methods of virtual reality training. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the standardised mean difference with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We included 23 trials with 612 participants. Four trials compared virtual reality versus video trainer training. Twelve trials compared virtual reality versus no training or standard laparoscopic training. Four trials compared virtual reality, video trainer training and no training, or standard laparoscopic training. Three trials compared different methods of virtual reality training. Most of the trials were of high risk of bias. In trainees without prior surgical experience, virtual reality training decreased the time taken to complete a task, increased accuracy, and decreased errors compared with no training; virtual reality group was more accurate than video trainer training group. In the participants with limited laparoscopic experience, virtual reality training reduces operating time and error better than standard in the laparoscopic training group; composite operative performance score was better in the virtual reality group than in the video trainer group. AUTHORS' CONCLUSIONS Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Further research of better methodological quality and more patient-relevant outcomes are needed.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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522
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Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev 2009:CD006575. [PMID: 19160288 DOI: 10.1002/14651858.cd006575.pub2] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. OBJECTIVES To determine whether virtual reality training can supplement or replace conventional laparoscopic surgical training (apprenticeship) in surgical trainees with limited or no prior laparoscopic experience. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and grey literature until March 2008. SELECTION CRITERIA We included all randomised clinical trials comparing virtual reality training versus other forms of training including video trainer training, no training, or standard laparoscopic training in surgical trainees with little or no prior laparoscopic experience. We also included trials comparing different methods of virtual reality training. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the standardised mean difference with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We included 23 trials with 612 participants. Four trials compared virtual reality versus video trainer training. Twelve trials compared virtual reality versus no training or standard laparoscopic training. Four trials compared virtual reality, video trainer training and no training, or standard laparoscopic training. Three trials compared different methods of virtual reality training. Most of the trials were of high risk of bias. In trainees without prior surgical experience, virtual reality training decreased the time taken to complete a task, increased accuracy, and decreased errors compared with no training; virtual reality group was more accurate than video trainer training group. In the participants with limited laparoscopic experience, virtual reality training reduces operating time and error better than standard in the laparoscopic training group; composite operative performance score was better in the virtual reality group than in the video trainer group. AUTHORS' CONCLUSIONS Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Further research of better methodological quality and more patient-relevant outcomes are needed.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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523
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Laparoscopic 3-step restorative proctocolectomy: comparative study with open approach in 45 patients. Surg Laparosc Endosc Percutan Tech 2009; 18:357-62. [PMID: 18716534 DOI: 10.1097/sle.0b013e3181772d75] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND To compare the results of a total laparoscopic versus open approach 3-time ileal pouch anal anastomosis (IPAA) for patients with acute or severe colitis complicating inflammatory bowel disease. METHODS Consecutive subtotal colectomy was followed by IPAA then by stoma closure. Between 2000 and 2006, 23 consecutive patients, operated through a total laparoscopic approach were well matched with 22 patients operated by open approach. RESULTS Overall major complications rate was lower after laparoscopic than after open approach (5/23 vs. 9/22; NS). Mean hospital stay for the 3 consecutive procedures was significantly reduced after laparoscopic versus open approach (27+/-7 d vs. 39+/-27 d; P<0.05). CONCLUSIONS Our case-control study suggests that, in experienced centers, a total laparoscopic approach can be viewed as a viable alternative to conventional open 3-step IPAA for the treatment of acute or severe colitis complicating inflammatory bowel disease.
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524
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Seo K, Choi Y, Choi J, Yoon K. Laparoscopic Appendectomy is Feasible for Inexperienced Surgeons in the Early Days of Individual Laparoscopic Training Courses. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.76.1.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kyungwon Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Youngil Choi
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Jaeyoung Choi
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
| | - Kiyoung Yoon
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
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525
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Park IJ, Choi GS, Lim KH, Kang BM, Jun SH. Multidimensional analysis of the learning curve for laparoscopic colorectal surgery: lessons from 1,000 cases of laparoscopic colorectal surgery. Surg Endosc 2008; 23:839-46. [PMID: 19116741 DOI: 10.1007/s00464-008-0259-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Revised: 10/15/2008] [Accepted: 11/15/2008] [Indexed: 02/06/2023]
Abstract
PURPOSE We consider quality of surgery throughout the learning curve and attempt to determine the learning curve for competency in performing laparoscopic colorectal surgery. METHODS The study included 1,014 patients who underwent laparoscopic colorectal resection between June 1996 and December 2007. We categorized patients into nine periods according to number of cases performed. RESULTS Operative time continuously decreased for right hemicolectomy (216 versus 150 min) and anterior resection (214.8 versus 147.7 min), whereas for low anterior resection it did not change over many periods and then significantly decreased after the ninth period (221.3 versus 176.4 min). The proportion of patients who had undergone previous abdominal surgery increased after the second period. Anastomotic leakage rate was 6-9% for the first 200 cases, and then decreased to less than 2%. More than 10% of operations were converted to open surgery during the first period, after which this rate significantly decreased to 2%. Number of harvested lymph nodes stabilized to 35-40 for right hemicolectomy after 200 cases, whereas for anterior and low anterior resection it was consistently 15-20 after the initial 20 cases. Overall, disease recurrence rate was 16-25%. For rectal cancer, local recurrence rate was highest (12%) in the fourth period and decreased thereafter to about 3%. CONCLUSION Postoperative complications and local recurrence rate increased even after accumulation of experience because of expansion of indications for laparoscopic procedures.
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Affiliation(s)
- In Ja Park
- Department of Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 50, Samduk-dong 2ga, Jung-gu, Daegu, South Korea.
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526
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Dinis-Ribeiro MJ, Correia RC, Santos C, Fernandes S, Palhares E, Silva RA, Amaro P, Areia M, Costa-Pereira A, Moreira-Dias L. Web-based system for training and dissemination of a magnification chromoendoscopy classification. World J Gastroenterol 2008; 14:7086-92. [PMID: 19084915 PMCID: PMC2776838 DOI: 10.3748/wjg.14.7086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the use of web-based technologies to assess the learning curve and reassess reproducibility of a simplified version of a classification for gastric magnification chromoendoscopy (MC).
METHODS: As part of a multicenter trial, a hybrid approach was taken using a CD-ROM, with 20 films of MC lasting 5 s each and an “autorun” file triggering a local HTML frameset referenced to a remote questionnaire through an Internet connection. Three endoscopists were asked to prospectively and independently classify 10 of these films randomly selected with at least 3 d apart. The answers were centrally stored and returned to participants together with adequate feedback with the right answer.
RESULTS: For classification in 3 groups, both intra- [Cohen’s kappa (κ) = 0.79-1.00 to 0.89-1.00] and inter-observer agreement increased from 1st (moderate) to 6th observation (κ = 0.94). Also, agreement with reference increased in the last observations (0.90, 1.00 and 1.00, for observers A, B and C, respectively). Validity of 100% was obtained by all observers at their 4th observation. When a 4th (sub)group was considered, inter-observer agreement was almost perfect (κ = 0.92) at 6th observation. The relation with reference clearly improved into κ (0.93-1.00) and sensitivity (75%-100%) at their 6th observations.
CONCLUSION: This MC classification seems to be easily explainable and learnable as shown by excellent intra- and inter-observer agreement, and improved agreement with reference. A web system such as the one used in this study may be useful for endoscopic or other image based diagnostic procedures with respect to definition, education and dissemination.
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527
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Hermsen PEA, Ayodeji ID, Hop WHC, Tetteroo GWM, de Graaf EJR. Harmonic long shears further reduce operation time in transanal endoscopic microsurgery. Surg Endosc 2008; 23:2124-30. [PMID: 19067055 PMCID: PMC2730445 DOI: 10.1007/s00464-008-0236-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 08/14/2008] [Accepted: 10/07/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS). METHODS Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm(2)) were excised in 161 patients (82 men, 79 women; mean age 66 years). RESULTS Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm(2); Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p < 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p < 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p < 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann-Whitney U-test: p < 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p < 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test). CONCLUSION Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments.
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Affiliation(s)
- Pleun E A Hermsen
- Department of Surgery, IJsselland Hospital, Prins Constantijnweg 2, Capelle aan den IJssel, 2906 ZC, The Netherlands
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528
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Gupta A, Chang D, Steele KE, Schweitzer MA, Lyn-Sue J, Lidor AO. Looking beyond age and co-morbidities as predictors of outcomes in paraesophageal hernia repair. J Gastrointest Surg 2008; 12:2119-24. [PMID: 18846407 DOI: 10.1007/s11605-008-0685-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 08/20/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes. METHODS We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001-2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)). RESULTS Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference. CONCLUSIONS While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.
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Affiliation(s)
- Anirban Gupta
- Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 610, Baltimore, MD 21287, USA
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529
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Boyle E, Ridgway PF, Keane FB, Neary P. Laparoscopic colonic resection in inflammatory bowel disease: minimal surgery, minimal access and minimal hospital stay. Colorectal Dis 2008; 10:911-5. [PMID: 19037931 DOI: 10.1111/j.1463-1318.2008.01518.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Laparoscopic surgery for inflammatory bowel disease (IBD) is technically demanding but can offer improved short-term outcomes. The introduction of minimally invasive surgery (MIS) as the default operative approach for IBD, however, may have inherent learning curve-associated disadvantages. We hypothesise that the establishment of MIS as the standard operative approach does not increase patient morbidity as assessed in the initial period of its introduction into a specialised unit, and that it confers earlier postoperative gastrointestinal recovery and reduced hospitalisation compared with conventional open resection. METHOD A case-control study was undertaken on laparoscopic resection (LR) vs open colon resection (OR) for IBD. The LR group was collated prospectively and compared with a pathologically matched historical control set. Outcomes measured included: postoperative length of stay, time to normal bowel function and postoperative morbidity. Statistical analysis was performed using spss. RESULTS Twenty-eight patients were investigated (14 LR, 14 OR). The two groups were matched for type of operation, type of disease and age. There were no conversions in the LR group. Morbidity and readmissions did not differ significantly between the groups. Those undergoing laparoscopic resection had a quicker return to diet (median 2 vs 4 days; P = 0.000002), time to first bowel motion (2 vs 4 days; P = 0.019) and shorter postoperative length of stay (5.5 vs 12.5; P = 0.0067). CONCLUSION These findings support the routine use of MIS for the elective surgical management of IBD in our department. Patients undergoing laparoscopic colectomies for IBD can expect faster return of gastrointestinal function and shorter hospitalisation.
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Affiliation(s)
- E Boyle
- Division of Colorectal Surgery, Minimally Invasive Surgery Tallaght, Adelaide, Ireland
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530
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Zhang X, Tanigawa N. Learning curve of laparoscopic surgery for gastric cancer, a laparoscopic distal gastrectomy-based analysis. Surg Endosc 2008; 23:1259-64. [PMID: 18813988 DOI: 10.1007/s00464-008-0142-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 07/30/2008] [Accepted: 08/13/2008] [Indexed: 12/28/2022]
Abstract
BACKGROUND The application of laparoscopic gastrectomy in management of gastric cancer is being propagated rapidly. Training and education play important role during this process. The purpose of this study is to define the learning curve of laparoscopic gastrectomy to obtain an insight into this training process. METHODS All 362 cases of laparoscopic gastrectomy from January 1998 to July 2007 were enrolled and divided into 12 groups of 30 cases each in time sequence. The learning curve was defined with the split group method. Laparoscopic distal gastrectomy was extracted from the 12 groups and the means of operation time and intraoperative blood loss were compared to define the learning curve. Then general data and variables including occurrence of systematic inflammatory response syndrome (SIRS), complications, and conversion to open surgery were compared among the phases of learning curve. RESULTS A three-phase learning curve of laparoscopic gastrectomy was defined from the laparoscopic distal gastrectomy-based analysis, which included a training phase for the first 120 cases of operation, an intermediate phase for the following 90 cases, and a well-developed phase for the last 152 cases. Learning was considered to be complete after 60-90 operations in the training phase. For most variables, the differences among three phases were statistically significant except for the rate of complications. CONCLUSIONS There was a significant learning curve, composed of three phases. Experience of about 60-90 cases of operation was required for completion of learning.
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Affiliation(s)
- Xiaoqiao Zhang
- Department of General and Gastroenterological Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
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Huirne JAF, Kennedy R, Stolzenberg JU, Brölmann HAM. What is the impact of surgical expertise and how to get it? ACTA ACUST UNITED AC 2008. [DOI: 10.1007/s10397-008-0425-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AbstractEvery surgeon will experience a learning curve while performing a new surgical procedure. Developing surgical training will shorten the learning curve, with less deleterious effects on patients during this period. There are exciting initiatives in different branches of surgical training that will be applicable across all surgical disciplines. These involve the combination of didactic repetitive training, coupled with skills training where it is applicable. These initiatives will help to move the focus, from developing technical excellence for a few individual surgeons to a more widespread approach in the training of complex laparoscopic surgery, resulting in considerable health benefits to patients.
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532
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Laparoscopic resection for colorectal cancer: evidence to date. Surg Oncol Clin N Am 2008; 17:519-31, viii. [PMID: 18486881 DOI: 10.1016/j.soc.2008.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article highlights the individual merits and weaknesses of laparoscopic as compared with open surgery as the primary treatment of colorectal cancer. Although results clearly suggest that laparoscopic surgery for colorectal cancer results in an earlier postoperative recovery, it is more difficult to comment on rarer complications. To date, results from laparoscopic colorectal resections suggest that the resected specimen is oncologically comparable that obtained with open surgery, but more long-term data on cancer recurrence and survival at 3 and 5 years postoperatively are eagerly awaited.
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533
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Gurusamy K, Aggarwal R, Palanivelu L, Davidson BR. Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery. Br J Surg 2008; 95:1088-97. [DOI: 10.1002/bjs.6344] [Citation(s) in RCA: 297] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Abstract
Background
Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience.
Methods
Randomized clinical trials addressing this issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, grey literature and reference lists. Standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.
Results
Twenty-three trials (mostly with a high risk of bias) involving 622 participants were included in this review. In trainees without surgical experience, VR training decreased the time taken to complete a task, increased accuracy and decreased errors compared with no training. In the same participants, VR training was more accurate than video trainer (VT) training. In participants with limited laparoscopic experience, VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training. In these participants, the composite performance score was better in the VR group than the VT group.
Conclusion
VR training can supplement standard laparoscopic surgical training. It is at least as effective as video training in supplementing standard laparoscopic training.
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Affiliation(s)
- K Gurusamy
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, University College London and Royal Free Hospital NHS Trust, London NW3 2QG, UK
| | - R Aggarwal
- Department of Biosurgery and Surgical Technology, Imperial College, London, UK
| | - L Palanivelu
- Department of Obstetrics and Gynaecology, Milton Keynes General NHS Trust, Milton Keynes, UK
| | - B R Davidson
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, University College London and Royal Free Hospital NHS Trust, London NW3 2QG, UK
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534
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Colquhoun PHD. CUSUM analysis of J-pouch surgery reflects no learning curve after board certification. Can J Surg 2008; 51:296-299. [PMID: 18815654 PMCID: PMC2552948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To investigate changes in morbidity and mortality associated with ileal J-pouch surgery performed during the first 3 years of a single surgeon's practice to determine the presence or absence of a learning curve after fellowship training. METHODS From July 2002 to July 2005, an observational study of postoperative outcomes was undertaken, in which 30-day and inhospital morbidity and mortality were assessed. A total of 37 patients (17 women and 20 men) underwent the surgery; their average age was 32 (range 16-51) years. The operation was performed for ulcerative colitis n = 31), familial adenomatous polyposis n = 4) and indeterminate colitis n = 2); 32 were diverted and 5 were not. Predicted morbidity and mortality were 31.66% and 1.47%, respectively. Observed morbidity and mortality were 29.7% and 0%, respectively. I used a risk-adjusted cumulative sum (CUSUM) model to compare observed outcomes with predicted outcomes according to a validated scoring system and to analyze outcomes with adjusting for risk on a case-by-case basis. RESULTS CUSUM analysis revealed a flat curve trending down over the duration. CONCLUSION CUSUM methodology permits documentation of quality control during the first 3 years of practice. The experience of a single board-certified colorectal surgeon reveals acceptable results in the first 3 years of practice, with no obvious learning curve. The results suggest that fellowship training and board certification conferred reasonable proficiency in J-pouch surgery before the onset of practice.
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535
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Bouchard A, Martel G, Sabri E, Schlachta CM, Poulin ÉC, Mamazza J, Boushey RP. Does experience with laparoscopic colorectal surgery influence intraoperative outcomes? Surg Endosc 2008; 23:862-8. [DOI: 10.1007/s00464-008-0087-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 06/17/2008] [Accepted: 06/23/2008] [Indexed: 12/23/2022]
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536
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Buchanan GN, Malik A, Parvaiz A, Sheffield JP, Kennedy RH. Laparoscopic resection for colorectal cancer. Br J Surg 2008; 95:893-902. [PMID: 18551725 DOI: 10.1002/bjs.6019] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study examined one surgeon's practice to determine the place of laparoscopic colorectal cancer surgery. METHODS Some 365 patients undergoing elective colorectal cancer resection (219 colonic, 146 rectal) were studied prospectively. Early (1994-1997; 104 patients), middle (1998-2001; 112) and late (2002-2005; 149) cohorts were analysed with respect to suitability for laparoscopic surgery, conversion and outcome. RESULTS Forty-six of 135 patients undergoing open resection were suitable for laparoscopic surgery but randomized to open surgery. The proportion of attempted laparoscopic resections (35.6, 65.2 and 80.6 per cent in early, middle and late cohorts) and patients thought suitable for laparoscopic resection (37.5, 87.5 and 94.0 per cent respectively; P = 0.001) increased over time. Independent predictors of conversion were rectal cancer surgery (odds ratio (OR) 3.12 versus colonic surgery) and body mass index 28 kg/m(2) or more (OR 3.87). Conversion was necessary in all five patients with a threatened margin predicted by preoperative magnetic resonance imaging. After exclusion of these patients the conversion rate in the late cohort was 8.7 per cent. During the same period, inclusion of 20 patients who were suitable for laparoscopic surgery but underwent open resection meant that 135 (90.6 per cent) of 149 patients were actually suitable for laparoscopic resection. CONCLUSION With experience, laparoscopic surgery is feasible in around 90 per cent of elective colorectal cancer resections.
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Affiliation(s)
- G N Buchanan
- Department of Surgery, Yeovil Hospital, Yeovil, UK
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537
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Construct validation of a novel hybrid virtual-reality simulator for training and assessing laparoscopic colectomy; results from the first course for experienced senior laparoscopic surgeons. Surg Endosc 2008; 22:2301-9. [DOI: 10.1007/s00464-008-9900-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 02/11/2008] [Accepted: 03/04/2008] [Indexed: 12/25/2022]
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538
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Abstract
Learning curves are often referred to in the context of medical education and training, though their trajectories and natures are a matter of debate. The origins of this concept derive from industry and its relevance to contemporary medicine and surgery remains controversial. We describe the history, derivation, character and possible mechanisms to deal with the implications of learning curves in the current climate of clinical governance and modernizing medical careers.
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Affiliation(s)
- A N Hopper
- Department of Surgery, Nevill Hall Hospital, Brecon Road, Abergavenny NP7 7EG, UK.
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539
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Guerrieri M, Campagnacci R, De Sanctis A, Baldarelli M, Coletta M, Perretta S. The learning curve in laparoscopic adrenalectomy. J Endocrinol Invest 2008; 31:531-6. [PMID: 18591886 DOI: 10.1007/bf03346403] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most adrenal tumors. LA learning curve (LC) varies among surgeons and may be influenced by factors depending on surgeon, patient, and lesion peculiarities. The aim of this study was to evaluate the LC by multi-dimensional analysis. METHODS Between August 1994 and August 2005, 241 LA were performed in our department. Data were prospectively collected. The pre-operative variables evaluated were patient-related (age, gender, body mass index, co-morbidities) and disease-related (histology, size, and side of lesion). Level of experience of surgical team and surgical approach (anterior, flank, submesocolic routes) were evaluated as well. Flank approached and bilateral procedures were excluded, while submesocolic LA, were collected separately. Operating time (OpT), conversion rate (CR), intra-operative and post-operative complications were evaluated. Patient, surgeon, and procedure-related factors involved in LC were investigated by a multi-factorial logistic regression analysis. RESULTS Body mass index, side, size, histology, technology improvement, and experience of surgical team, evaluated through the progressive series of surgical procedures, were independent predictors of CR and OpT. The CR for right adrenalectomy was 3% (3 cases) compared to 4.2% for left side (6 cases). The submesocolic approach significantly influenced OpT, but not CR. Mean OpT for right and left LA was 83 and 109 min, respectively. Based on surgical experience increase, the OpT and CR flattened their curves, roughly at 30 and 40 procedures for right and left LA, respectively. Post-operative complications did not change considerably throughout the series. Readmission rate within 30 days was negligible. CONCLUSIONS Manifold factors may affect LC and outcome in LA. Their knowledge may support teaching activities as well as reducing conversion and complication rates.
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Affiliation(s)
- M Guerrieri
- Clinica di Chirurgia Generale e Metodologia Chirurgica, Ospedali Riuniti, 60121 Ancona, Italy
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540
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Effect of obesity on technical feasibility and postoperative outcomes of laparoscopy-assisted distal gastrectomy--comparison with open distal gastrectomy. J Gastrointest Surg 2008; 12:997-1004. [PMID: 17955310 DOI: 10.1007/s11605-007-0374-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 09/21/2007] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to compare outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) in obese and non-obese patients. METHODS Subjects comprised 248 consecutive patients who underwent distal gastrectomy for gastric cancer between January 1999 and December 2005. Patients with body mass index (BMI) > or = 25 kg/m2 were defined as obese, and patients with BMI < 25 kg/m2 were defined as non-obese. Parameters analyzed included patients characteristics, tumor characteristics, operative details, postoperative outcomes, and prognosis. RESULTS For LADG, 35 patients were considered obese, and 106 patients were non-obese. For ODG, 25 patients were considered obese, and 82 patients were non-obese. Mean operative times in each procedure were significantly longer for the obese group than for the non-obese group (ODG: 241.4 min vs. 199.5 min, p < 0.0001; LADG: 279.6 min vs. 255.3 min, p = 0.03). Blood loss was significantly higher for the obese group than for the non-obese group in ODG (300 ml vs. 400 ml, p = 0.024), but no significant differences were observed between obese and non-obese groups for LADG. Incidence of major postoperative complications, number of retrieved lymph nodes, and disease-free survival rates were similar in obese and non-obese groups for each procedure. CONCLUSIONS Our analysis revealed that LADG can be safely performed in obese patients, with complication rates and operation outcomes similar to those for non-obese patients.
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541
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Aggarwal R, Grantcharov T. Laparoscopic Colorectal Surgical Training: A Curricular Approach. SEMINARS IN COLON AND RECTAL SURGERY 2008. [DOI: 10.1053/j.scrs.2008.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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542
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Champagne BJ, Lee EC, Valerian B, Armstrong D, Ambroze W, Orangio G. A novel end point to assess a resident's ability to perform hand-assisted versus straight laparoscopy for left colectomy: is there really a difference? J Am Coll Surg 2008; 207:554-9. [PMID: 18926459 DOI: 10.1016/j.jamcollsurg.2008.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/04/2008] [Accepted: 03/05/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND It has been suggested that hand-assisted colectomy (HAC) may help residents progress along the learning curve, but there is currently no evidence to support this claim. Previous studies address procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary end points. We measured the percentage of cases completed by a resident as the operating surgeon as the primary end point to determine the most effective approach for teaching laparoscopic colectomy. STUDY DESIGN All patients who underwent left-sided HAC or straight laparoscopic colectomy (SLC) by a single resident starting as the primary surgeon were included. If the assisting attending physician assumed the role of the operating surgeon during the case, it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end points. RESULTS A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship, including 81 left-sided procedures. There were 44 patients in the HAC group and 37 SLC patients. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC, 88%; HAC, 72%; p=0.06). There were also differences in mean operative time favoring SLC (HAC, 142 minutes [range 100 to 170 minutes] versus SLC, 133 minutes [range 95 to 195 minutes]; p=0.04). Complications were similar in the 2 groups (HAC, 19% versus SLC, 21%), as were conversions (HAC, 5.6% versus SLC, 4.5%). CONCLUSIONS Both hand-assisted and straight laparoscopic techniques for left colectomy can be applied to successfully train surgical residents with the assistance of a staff surgeon outside of their learning curve. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach during training.
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543
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Veenhof AAFA, Engel AF, van der Peet DL, Sietses C, Meijerink WJHJ, de Lange-de Klerk ESM, Cuesta MA. Technical difficulty grade score for the laparoscopic approach of rectal cancer: a single institution pilot study. Int J Colorectal Dis 2008; 23:469-75. [PMID: 18185936 PMCID: PMC2668628 DOI: 10.1007/s00384-007-0433-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2007] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We aimed to categorize laparoscopic rectal resections according to technical difficulty to standardize learning purposes and stratify results, making future studies more comparable. MATERIALS AND METHODS Fifty patients undergoing a laparoscopic total mesorectal excision were prospectively followed. Four preoperatively known facts (gender, body mass index (BMI), tumor localization, and preoperative radiation therapy) were compared to four operative outcomes (operation time, blood loss, a visual analogue score (VAS) for difficulty rewarded by the surgeon, and oncological radicality of the procedure). RESULTS Operating time for male and female patients was 257 vs. 245 min (P=0.229), blood loss was 300 vs. 300 ml (P=0.309), the VAS was 8 vs. 6 (P<0.001), and radicality was 93% vs. 91% (P=0.806). Operating time was 215, 250, and 305 min for high, mid, and low tumors (Spearman -0.44; P=0.02), respectively. Blood loss was 105, 300, and 600 ml (Spearman -0.38; P=0.01). Lower tumors were rewarded a higher VAS (Spearman -0.57; P<0.001) and were less often radically resected (Spearman 0.32; P=0.026). Operating time for irradiated and nonirradiated patients was 277 vs. 225 min (P=0.008), blood loss was 500 vs. 150 ml (P=0.006), the VAS was 7 vs. 5 (P<0.001), and radicality was 79% vs. 100% (P=0.046). Operating time was 240 min for BMI 25-30 and 253 min for BMI>30 (Spearman 0.13; P=0.391). Blood loss was 150 ml for BMI 25-30 and 500 ml for BMI>30 (Spearman 0.38; P=0.01). Higher BMIs were rewarded a higher VAS (Spearman 0.06; P=0.704). BMI had no correlation to radicality of the procedure (Spearman -0.12; P=0.402). There was an association between technical difficulty score and operation time (P=0.007), blood loss (P<0.001), VAS (P<0.001), and radicality of surgery (P=0.043). CONCLUSION Laparoscopic surgery in male, irradiated, and obese patients with lower tumors seemed more difficult. A categorization according to technical difficulty, to preoperatively predict difficulty of the procedure, was found feasible.
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Affiliation(s)
- A. A. F. A. Veenhof
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - A. F. Engel
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands
| | - D. L. van der Peet
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - C. Sietses
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - W. J. H. J. Meijerink
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
| | - E. S. M. de Lange-de Klerk
- Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - M. A. Cuesta
- Departments of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB Amsterdam, The Netherlands
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544
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Aalbers AGJ, Biere SSAY, van Berge Henegouwen MI, Bemelman WA. Hand-assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2008; 22:1769-80. [PMID: 18437486 PMCID: PMC2471396 DOI: 10.1007/s00464-008-9857-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 01/21/2008] [Accepted: 02/07/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence of benefits of laparoscopic and laparoscopic-assisted colectomies (LAC) over open procedures in gastrointestinal surgery has continued to accumulate. With its wide implementation, technical difficulties and limitations of LAC have become clear. Hand-assisted laparoscopic surgery (HALS) was introduced in an attempt to facilitate the transition from open techniques to minimally invasive procedures. Continuing debate exists about which approach is to be preferred, HALS or LAC. Several studies have compared these two techniques in colorectal surgery, but no single study provided evidence which procedure is superior. Therefore, a systematic review was carried out comparing HALS with LAC colorectal resection. METHODS Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment, and data extraction were independently performed by two reviewers. Minimal outcome criteria for inclusion were operating time, conversion rate, hospital stay, and morbidity. RESULTS Out of 468 studies a total of 13 studies were selected for comprehensive review. Two randomized controlled trials (RCT) and 11 non-RCTs, comprising 1017 patients, met the inclusion criteria. Because of possible clinical heterogeneity two groups of procedures were created: segmental colectomies and total (procto)colectomies. In the segmental colectomy group significant differences in favor of the HALS group were seen in operating time (WMD 19 min) and conversion rate (OR of 0.3 conversions). In the total (procto)colectomy group a significant difference in favor of the HALS group was seen in operating time (WMD 61 min). CONCLUSIONS This systematic review indicates that HALS provides a more efficient segmental colectomy regarding operating time and conversion rate, particularly accounting for diverticulitis. A significant operating time advantage exists for HALS total (procto)colectomy. HALS must therefore be considered a valuable addition to the laparoscopic armamentarium to avoid conversion and speed up complicated colectomies.
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Affiliation(s)
- A G J Aalbers
- Department of Surgery, Academic Medical Center, Location G4-129, Postbox 22660, 1100 DD, Amsterdam, The Netherlands
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545
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Agha A, Fürst A, Iesalnieks I, Fichtner-Feigl S, Ghali N, Krenz D, Anthuber M, Jauch KW, Piso P, Schlitt HJ. Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome. Int J Colorectal Dis 2008; 23:409-17. [PMID: 18185938 DOI: 10.1007/s00384-007-0425-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2007] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The negative influence of conversion from laparoscopic to open colorectal resection on early postoperative morbidity and outcome has been demonstrated several times. In this study, we analyzed the conversion rate and its influence on early postoperative morbidity and short-term oncological outcome following laparoscopic rectal resections. METHODS From January 1998 to December 2006, 300 patients underwent laparoscopic resection due to rectal carcinoma at our institution. We compared the converted patient group with the non-converted patient group regarding demographical, clinical, surgical, and histological data, compounded with the early and late postoperative results. RESULTS Two hundred seventy-four (91.3%) patients underwent laparoscopic rectal resection (LR), while conversion resection (CR) was necessary in 26 cases (8.6%). Conversion rate was 13% during the first 100 resections and decreased to 3% during the last 100 procedures (p = 0.035). Male gender, higher body mass index, and presence of T4-tumor were risk factors for conversion. Early postoperative complications were more frequent in the CR group than in the LR group. Concerning local tumor recurrence and overall survival, there was no significant difference between both groups (local recurrence, CR at 3.8% vs. LR at 4.5% and overall survival rate, CR at 76.9% vs. LR at 89.1%) after a median follow-up period of 22.5 months. CONCLUSION Conversion to an open procedure during laparoscopic rectal resection correlates with an increased postoperative morbidity, however, without impairment of the short-term oncological outcome. The conversion rate is minimized by the growing experience of the operating surgeon and, therefore, is a marker of the learning curve.
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Affiliation(s)
- A Agha
- Klinik und Poliklinik für Chirurgie, Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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546
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A single training center's experience with 200 consecutive cases of diverticulitis: can all patients be approached laparoscopically? Surg Endosc 2008; 22:2503-8. [PMID: 18347863 DOI: 10.1007/s00464-008-9818-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 02/04/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to evaluate the outcomes for consecutive patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy. METHODS Data for this patient population were collected by chart review and analyzed retrospectively. RESULTS Between December 2001 and March 2007, 200 consecutive patients (93 men and 107 women) with an average age of 55 years were identified. All cases were managed by one of two colorectal surgeons. Of the 200 patients, 158 had recurrent diverticulitis, 20 had fistulas, 12 had abscesses, 8 had strictures, 1 had a mass, and 1 had a bleed. The mean operative time was 159 min, and the conversion rate was 8%. A total of 30 early postoperative complications occurred for 26 patients including wound infection (n = 9), ileus (n = 8), Clostridium difficile colitis (n = 3), urinary retention (n = 3), pelvic abscess (n = 2), deep vein thrombosis and pulmonary embolism (n = 1), pneumonia (n = 1) urinary tract infection (n = 1), anastomotic leak (n = 1), and small bowel obstruction (n = 1). Late complications experienced by 11 patients included Clostridium difficile colitis (n = 3), incisional hernia (n = 3), wound infection (n = 3), wound hematoma (n = 1), and intraabdominal hemorrhage (n = 1). CONCLUSIONS The authors believe it is feasible to offer elective laparoscopic sigmoid colectomy to all patients with symptomatic diverticular disease despite preoperative risk factors.
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547
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Feasibility of laparoscopic techniques as the surgical approach of choice for primary colorectal cancer: an analysis of 570 consecutive cases. Surg Endosc 2008; 22:2588-95. [PMID: 19011948 DOI: 10.1007/s00464-008-9814-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 12/18/2007] [Accepted: 01/24/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the Clinical Outcomes of Surgical Therapy (COST) trial data were reported in May 2004, the laparoscopic technique for primary colorectal cancer has been increasingly used and become the approach of choice at our center. This study aimed to evaluate our laparoscopic experience of 570 consecutive patients between October 2000 and December 2006, and assess the feasibility of this technique as the surgical approach of choice for primary colorectal cancer. METHODS The study times were divided into three periods based on the COST trial report and the time when the laparoscopic technique was accepted as the surgical approach of choice at our center (period I: October 2000 to May 2004, II: June 2004 to December 2005, III: January to December 2006). Data regarding clinicopathological, surgical, and perioperative outcomes were collated from registry and compared between periods. RESULTS The use of laparoscopic surgery increased from 2.4% in period I, to 19.2% in period II, to 66.1% in period III. Over the periods, the proportion of rectal cancer and right colon cancer increased (p < 0.001), T- and N-stage became more advanced (p < 0.001, p = 0.011 respectively), and operative time decreased (p < 0.001). The overall open conversion and morbidity rates were 3.5% and 9.8%, respectively, and these did not differ between periods. CONCLUSION It was possible to apply laparoscopic approach in two-thirds of primary colorectal cancer patients. The short-term favorable outcomes support the feasibility of laparoscopic technique as surgical approach of choice for colon cancer. Laparoscopic resection for rectal cancer may require a randomized clinical trial prior to gain similar acceptance.
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548
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Wright RC, Kim CA, Horner I, Wright R. Superior Lymph Node Resection is Achievable with Laparoscopic Colectomy: Even in Initial 30 Cases. Am Surg 2008. [DOI: 10.1177/000313480807400314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Recent studies demonstrated the validity of the laparoscopic technique in colon cancer resection. Recent node resection data for open colectomies show inadequate nodal removal is common. In this study, two experienced laparoscopic surgeons evaluated their initial outcomes with laparoscopic colectomy, including resections for malignancies. This retrospective review of clinic and hospital records involved 69 consecutive patients subjected to laparoscopic colectomies from July 2000 through December 2005. Outcomes were compared with 1000 patients from Senagore and Delaney. Adequacy of oncologic resection was compared with the published National Cancer Institute database. Sixty-nine resections were performed. Overall complication and conversion rates were comparable to Senagore and Delaney except for days of hospitalization at 6.0 compared with 3.7 (P < 0.01) and readmission of 4.2 per cent compared with 9.1 per cent (P < 0.01). Adequate node resection occurred in 26 of 32 patients (81%) compared with 37 per cent of open colectomies in the National Cancer Institute nationwide database (P < 0.05). The overall median number of nodes resected was 18. For veteran laparoscopic surgeons in a community hospital, the initial experience with laparoscopic colectomy can provide excellent results, meeting standards set in large published series. In addition, the resection of nodes in colon cancer can be significantly better when performed laparoscopically or by hand-assisted laparoscopy.
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Affiliation(s)
- Robert C. Wright
- Department of Surgery, Good Samaritan Hospital, Puyallup, Washington
| | - C. Anthony Kim
- Department of Surgery, Good Samaritan Hospital, Puyallup, Washington
| | - Ian Horner
- Touro University, Vallejo, California; and
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549
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Chan ACY, Poon JTC, Fan JKM, Lo SH, Law WL. Impact of conversion on the long-term outcome in laparoscopic resection of colorectal cancer. Surg Endosc 2008; 22:2625-30. [PMID: 18297346 DOI: 10.1007/s00464-008-9813-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Revised: 01/17/2008] [Accepted: 01/24/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-term outcome of patients with conversion following laparoscopic resection of colorectal cancer has seldom been reported. This study aimed to evaluate the impact of conversion on the operative outcome and survival of patients who underwent laparoscopic resection for colorectal malignancy. METHODS An analysis of a prospectively collected database of 470 patients who underwent laparoscopic colectomy between May 2000 and December 2006 was performed. The operative results and long-term outcomes of patients with conversion were compared with those with successful laparoscopic operations. RESULTS The overall conversion rate to open surgery was 8.7% (41 patients). There was no difference in age, comorbid illness, location of tumor, and stage of disease between the laparoscopic and conversion groups. The most common reasons for conversion include adhesions (34.1%), tumor invasion into adjacent structures (17.1%), bulky tumor (9.8%), and uncontrolled hemorrhage (9.8%). A male preponderance was observed in the conversion group. Tumor size was significantly larger in the conversion group compared with the laparoscopic group (5 versus 4 cm, P = 0.002). Although there was no difference in the operative time between the two groups, increased perioperative blood loss (461.9 vs. 191.2 ml, P < 0.001), increased postoperative complication rate (56.1% versus 16.7%, P = 0.001) and prolonged median hospital stay (10 versus 6 days, P < 0.001) were associated with the conversion group. Consequently, patients in the conversion group were more likely to develop local recurrence (9.8% versus 2.8%, P < 0.001) with a significantly reduced cumulative cancer-free survival. CONCLUSION The disease-free survival and the local recurrence were significantly worse by the presence of conversion in laparoscopic resection for colorectal malignancy. Adoption of a standardized operative strategy may improve the perioperative outcome after conversion.
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Affiliation(s)
- Albert C Y Chan
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Pokfulam Road, Kowloon, Hong Kong
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Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience. Surg Endosc 2008; 23:622-8. [PMID: 18270771 DOI: 10.1007/s00464-008-9753-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 11/28/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. METHODS This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. RESULTS Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. CONCLUSION Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery.
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