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Grönroos-Korhonen MT, Kössi JAO. LapEmerge trial: study protocol for a laparoscopic approach for emergency colon resection-a multicenter, open label, randomized controlled trial. Trials 2024; 25:268. [PMID: 38632602 PMCID: PMC11022348 DOI: 10.1186/s13063-024-08058-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/14/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Due to faster recovery and lower morbidity rates, laparoscopy has become the gold standard in elective colorectal surgery for both the benign and malignant forms of the disease. A substantial proportion of colorectal operations are, however, carried out in emergency settings, and most of the emergency resections are still performed open. The aim of this study is to compare the laparoscopic versus open approach for emergency colorectal surgery. METHOD/DESIGN This is a multicenter prospective randomized controlled trial including adult patients presenting with a condition requiring emergency colorectal resection. DISCUSSION Previous studies cautiously recommend wider use of laparoscopy in emergency colorectal resections, but all earlier reports are retrospective, are mostly single-center studies, and have limited numbers of patients. Laparoscopy may involve some unpredictable risks that have not yet been reported because of the infrequent use of the techniqueded to assess the safety of laparoscopy as well as the advantages and disadvantages of open compared with laparoscopic emergency surgery. TRIAL REGISTRATION Trial registration number: ClinicalTrials.gov NCT05005117 . Registered on August 12, 2021.
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Affiliation(s)
- Marie T Grönroos-Korhonen
- Gastroenterological Surgery, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland.
- Helsinki University, Helsinki, Finland.
| | - Jyrki A O Kössi
- Gastroenterological Surgery, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
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Bass GA, Kaplan LJ, Gaarder C, Coimbra R, Klingensmith NJ, Kurihara H, Zago M, Cioffi SPB, Mohseni S, Sugrue M, Tolonen M, Valcarcel CR, Tilsed J, Hildebrand F, Marzi I. European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities. Eur J Trauma Emerg Surg 2024; 50:367-382. [PMID: 38411700 PMCID: PMC11035411 DOI: 10.1007/s00068-023-02441-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/28/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature. METHODS Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society. RESULTS Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training. CONCLUSIONS This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA.
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA, USA.
| | - Lewis Jay Kaplan
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
- Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
| | - Christine Gaarder
- Department of Traumatology at Oslo University Hospital Ullevål (OUH U), Olso, Norway
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Nathan John Klingensmith
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
| | - Hayato Kurihara
- State University of Milan, Milan, Italy
- Emergency Surgery Unit, Ospedale Policlinico di Milano, Milan, Italy
| | - Mauro Zago
- General & Emergency Surgery Division, A. Manzoni Hospital, ASST, Lecco, Lombardy, Italy
| | | | - Shahin Mohseni
- Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
- Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Michael Sugrue
- Letterkenny Hospital and Galway University, Letterkenny, Ireland
| | - Matti Tolonen
- Emergency Surgery, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, HUS, Finland
| | | | - Jonathan Tilsed
- Hull Royal Infirmary, Anlaby Road, Hu3 2Jz, Hull, England, UK
| | - Frank Hildebrand
- Department of Orthopaedics Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.
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Downey CL, Lessing J, Jayne DG. Reporting of health-related quality of life in emergency laparotomy trials: a systematic review and narrative synthesis. Qual Life Res 2024; 33:599-605. [PMID: 37882901 PMCID: PMC10894131 DOI: 10.1007/s11136-023-03531-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE Emergency laparotomy is associated with high morbidity for the surgical patient. Understanding patients' health-related quality of life after their surgery is important to enhance the informed consent process, and to enable the evaluation and improvement of surgical care. This review aims to summarise the use of health-related quality of life tools in clinical trials involving patients undergoing emergency laparotomy. METHODS A systematic review was undertaken of the scientific literature published in the MEDLINE® and PubMed databases between January 2011 and July 2021. A narrative synthesis approach was chosen to synthesise the diverse range of studies in a structured manner. All included papers were evaluated using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Eleven studies were selected for inclusion. Most of the studies had a low risk of bias. Two of the studies used health-related quality of life as the primary outcome measure. A variety of health-related quality of life measurement tools were used; the EQ-5D tool was the most popular questionnaire. Protocol adherence was dependent on the length of time which had elapsed after emergency surgery. CONCLUSION There are many perceived challenges to collecting health-related quality of life data in the emergency surgery setting. Many of these can be offset with progressive trial designs. There is a need for further research in the systematic development of patient-reported outcomes for use in emergency surgery.
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Affiliation(s)
- Candice L Downey
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, University of Leeds, Level 7, Clinical Sciences Building, Leeds, LS9 7TF, UK.
| | - J Lessing
- Leeds Teaching Hospital Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D G Jayne
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, University of Leeds, Level 7, Clinical Sciences Building, Leeds, LS9 7TF, UK
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Bunce JA, Doleman B, Lund JN, Tierney GM. The Impact of Surgeon Speciality Interest on Outcomes of Emergency Laparotomy in IBD. World J Surg 2023; 47:2287-2295. [PMID: 37222782 PMCID: PMC10387454 DOI: 10.1007/s00268-023-07051-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Emergency laparotomy may be required in patients with inflammatory bowel disease (IBD). NELA is the largest prospectively maintained database of adult emergency laparotomies in England and Wales and includes clinical urgency of the cases. The impact of surgeon subspeciality on outcomes after emergency laparotomy for IBD is unclear. We have investigated this association, according to the degree of urgency in IBD emergency laparotomy, including the effect of minimally invasive surgery (MIS). METHODS Adults with IBD in the NELA database between 2013 and 2016 were included. Surgeon subspeciality was colorectal or non-colorectal. Urgencies are 'Immediate', '2-6 h', '6-18 h' and '18-24 h'. Logistic regression was used to investigate in-patient mortality and post-operative length of stay (LOS). RESULTS There was significantly reduced mortality and LOS in IBD patients who were operated on by a colorectal surgeon in the least urgent category of emergency laparotomies; Mortality adjusted OR 2.99 (CI 1.2-7.8) P = 0.025, LOS IRR 1.18 (CI 1.02-1.4) P = 0.025. This association was not seen in more urgent categories. Colorectal surgeons were more likely to use MIS, P < 0.001, and MIS was associated with decreased LOS in the least urgent cohort, P < 0.001, but not in the other urgencies. CONCLUSIONS We found improved outcomes in the least urgent cohort of IBD emergency laparotomies when operated on by a colorectal surgeon in comparison to a non-colorectal general surgeon. In the most urgent cases, there was no benefit in the operation being performed by a colorectal surgeon. Further work on characterising IBD emergencies by urgency would be of value.
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Affiliation(s)
- J A Bunce
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK.
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
| | - G M Tierney
- Division of Health Sciences and Graduate Entry Medicine, Faculty of Medicine, Royal Derby Hospital, University of Nottingham at Derby, Derby, UK
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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Zhong W, Liu C, Fang C, Zhang L, He X, Zhu W, Guan X. Laparoscopic versus open surgery for colonoscopic perforation: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e34057. [PMID: 37327263 PMCID: PMC10270540 DOI: 10.1097/md.0000000000034057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND The efficacy of laparoscopic surgery (LS) for the treatment of colonoscopic perforation is still controversial. The purpose of this meta-analysis was to evaluate the effectiveness and safety of LS versus open surgery (OS) for colonoscopic perforation. METHODS All clinical trials that compared laparoscopic with OS for colonoscopic perforation published in English were identified in PubMed, EMBASE, Web of Science, and Cochrane Library searches. A modified scale was used to assess the quality of the literature. We analyzed the age, sex ratio, aim of colonoscopy, history of abdominopelvic surgery, type of procedure, size of perforation, operation time, postoperative fasting time, hospital stay, postoperative complication morbidity, and postoperative mortality. Meta-analyses were performed using weighted mean differences for continuous variables, and odds ratios for dichotomous variables. RESULTS No eligible randomized trials were identified, but eleven nonrandomized trials were analyzed. In the pooled data of 192 patients who underwent LS and 131 OS, there were no significant differences in age, sex ratio, aim of colonoscopy, history of abdominopelvic surgery, perforation size, and operative time between the groups. LS group had shorter time of hospital stay and postoperative fasting time, less postoperative complication morbidity, but there were no significant difference in postoperative mortality rate between LS group and OS group. CONCLUSIONS Based on the current meta-analysis, we conclude that LS is a safe and efficacious technique for colonoscopic perforation, with fewer postoperative complications, less hospital mortality, and faster recovery compared with OS.
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Affiliation(s)
- Wu Zhong
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Chuanyuan Liu
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Chuanfa Fang
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Lei Zhang
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Xianping He
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Weiquan Zhu
- Department of General Surgery, The Ganzhou People’s Hospital, Ganzhou, China
| | - Xueyun Guan
- Department of Pediatric, The Ganzhou People’s Hospital, Ganzhou, China
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Smyth R, Darbyshire A, Mercer S, Khan J, Richardson J. Trends in emergency colorectal surgery: a 7-year retrospective single-centre cohort study. Surg Endosc 2023; 37:3911-3920. [PMID: 36729232 DOI: 10.1007/s00464-023-09876-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/06/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Emergency colorectal resections carry a higher morbidity and mortality than elective surgery. The use of minimally invasive surgery has now become widespread in elective colorectal surgery, with improved patient outcomes. Laparoscopy is being increasingly used for emergency colorectal resections, but its role is still being defined. Our aim was to observe the uptake of laparoscopy for emergency colorectal surgery in our centre. METHOD A retrospective single-centre cohort study was performed using local National Emergency Laparotomy Audit data from January 2014-December 2020. All patients who had a colorectal resection were included. Trends in the number and type of resections were recorded. Primary outcome was the proportion of cases started and completed laparoscopically. Secondary outcomes included rate of conversion to open, length of stay and 30-day mortality. RESULTS A total 523 colorectal resections were performed. The number of cases attempted and completed laparoscopically steadily increased over the study period (28.3% to 63.3% and 16.3% to 35.4%, respectively). The mean rate of conversion to open was 43.8%. The greatest expansion in laparoscopy was for cases of intestinal obstruction, perforation and peritonitis, and for those undergoing Hartmann's procedure and right hemicolectomy. 30‑day mortality for cases completed laparoscopically was much lower than those converted or started with open surgery (2.1% vs 11.7% and 17.5%, respectively). Laparoscopic approach was independently associated with reduced length of stay. CONCLUSION Laparoscopy has been successfully adopted for emergency colorectal resections in our centre, with half of cases felt to be suitable for minimally invasive surgery.
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Affiliation(s)
- Rachel Smyth
- MRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK.
| | - Alexander Darbyshire
- MRCS Upper GI Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - Stuart Mercer
- FRCS Upper GI Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - Jim Khan
- FRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John Richardson
- FRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
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Smart N. Editor's choice - Jan 2023. Colorectal Dis 2023; 25:4-5. [PMID: 36719028 DOI: 10.1111/codi.16480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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8
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Feasibility of laparoscopy and factors associated with conversion to open in minimally invasive emergency major abdominal surgery: population database analysis. Surg Endosc 2022; 36:4499-4506. [PMID: 34724578 DOI: 10.1007/s00464-021-08803-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 10/17/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND There is limited evidence regarding the overall feasibility and success rates of the laparoscopic approach in major emergency surgery, despite its potential to improve outcomes. This study aims to investigate the association between patient, procedural, and surgical factors and likelihood of successful laparoscopic completion in emergency major surgery and derive a predictive model to aid clinical decision-making. METHOD All patients recorded in the NELA emergency laparotomy database 1 December 2013-31 November 2018 who underwent laparoscopically attempted surgery were included. A retrospective cohort multivariable regression analysis was conducted for the outcome of conversion to open surgery. A predictive model was developed and internally validated. RESULTS Of 118,355 patients, 17,040 (7.7%) underwent attempted laparoscopic surgery, of which 7.915 (46.4%) were converted to open surgery. Procedure type was the strongest predictor of conversion (compared to washout as reference, small bowel resection OR 25.93 (95% CI 20.42-32.94), right colectomy OR 6.92 (5.5-8.71)). Diagnostic [free pus, blood, or blood OR 3.67 (3.29-4.1)] and surgeon [subspecialist surgeon OR 0.56 (0.52-0.61)] factors were also significant, whereas age, gender, and pre-operative mortality risk were not. A derived predictive model had high internal validity, C-index 0.758 (95% CI 0.748-0.768), and is available for free-use online. CONCLUSION Surgical, patient, and diagnostic variables can be used to predict likelihood of laparoscopic success with a high degree of accuracy. This information can be used to inform peri-operative decision-making and patient selection.
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Darbyshire AR, Kostakis I, Pucher PH, Prytherch D, Mercer SJ. P-POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database. World J Surg 2022; 46:552-560. [PMID: 35001139 DOI: 10.1007/s00268-021-06404-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom. METHODS A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality. RESULTS Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801-0.836; NELA Score 0.811-0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery. CONCLUSION Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.
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Affiliation(s)
- Alexander R Darbyshire
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY, UK.
| | - Ina Kostakis
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK
| | - Philip H Pucher
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY, UK
| | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK
| | - Stuart J Mercer
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY, UK
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Warps ALK, Zwanenburg ES, Dekker JWT, Tollenaar RAEM, Bemelman WA, Hompes R, Tanis PJ, de Groof EJ. Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting: A Systematic Review and Meta-analysis. ANNALS OF SURGERY OPEN 2021; 2:e097. [PMID: 37635817 PMCID: PMC10455067 DOI: 10.1097/as9.0000000000000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome. Background In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear. Methods PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment. Results Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed 'good quality' in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35-0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43-0.65), wound infection (OR, 0.63; 95% CI, 0.45-0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18-0.77), ileus (OR, 0.68; 95% CI 0.51-0.91), pulmonary (OR, 0.43; 95% CI, 0.24-0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35-0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data. Conclusions The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account.
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Affiliation(s)
- Anne-Loes K Warps
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Albinusdreef, Leiden, The Netherlands
- Dutch ColoRectal Audit (DCRA), Dutch Institute for Clinical Auditing, Rijnsburgerweg, Leiden, The Netherlands
| | - Emma S Zwanenburg
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Jan Willem T Dekker
- Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg, Delft, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Albinusdreef, Leiden, The Netherlands
- Dutch ColoRectal Audit (DCRA), Dutch Institute for Clinical Auditing, Rijnsburgerweg, Leiden, The Netherlands
| | - Willem A Bemelman
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Roel Hompes
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, de Boelelaan, Amsterdam, The Netherlands
| | - Elisabeth J de Groof
- From the Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef, Amsterdam, The Netherlands
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Linderman GC, Lin W, Sanghvi MR, Becher RD, Maung AA, Bhattacharya B, Davis KA, Schuster KM. Improved outcomes using laparoscopy for emergency colectomy after mitigating bias by negative control exposure analysis. Surgery 2021; 171:305-311. [PMID: 34332782 DOI: 10.1016/j.surg.2021.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/11/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopy is superior to open surgery for elective colectomy, but its role in emergency colectomy remains unclear. Previous studies were small and limited by confounding because surgeons may have selected lower-risk patients for laparoscopy. We therefore studied the effect of attempting laparoscopy for emergency colectomies while adjusting for confounding using multiple techniques in a large, nationwide registry. METHODS Using National Surgical Quality Improvement Program data, we identified emergency colectomy cases from 2014 to 2018. We first compared outcomes between patients who underwent laparoscopic versus open surgery, while adjusting for baseline variables using both propensity scores and regression. Next, we performed a negative control exposure analysis. By assuming that the group that converted to open did not benefit from the attempt at laparoscopy, we used the observed benefit to bound the effect of unmeasured confounding. RESULTS Of 21,453 patients meeting criteria, 3,867 underwent laparoscopy, of which 1,375 converted to open. In both inverse probability of treatment weighting and regression analyses, attempting laparoscopy was associated with improved 30-day mortality, overall morbidity, anastomotic leak, surgical site infection, postoperative septic shock, and length of hospital stay compared with open surgery. These effects were consistent with the lower bounds computed from the converted group. CONCLUSION Laparoscopic surgery for colorectal emergencies appears to improve outcomes compared with open surgery. The benefit is observed even after adjusting for both measured and unmeasured confounding using multiple statistical approaches, thus suggesting a benefit not attributable to patient selection.
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Affiliation(s)
- George C Linderman
- Department of Surgery, Yale School of Medicine, New Haven, CT; Applied Mathematics Program, Department of Mathematics, Yale University, New Haven, CT. https://twitter.com/GCLinderman
| | - Winston Lin
- Department of Statistics and Data Science, Yale University, New Haven, CT
| | - Mansi R Sanghvi
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Adrian A Maung
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, CT. https://twitter.com/kadtraumamd
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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