Outcomes for single-incision laparoscopic colectomy surgery in obese patients: a case-matched study

The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis

INTRODUCTION

We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018.

METHODS

A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes.

RESULTS

From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates.

CONCLUSION

When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.

Safety and efficacy of totally minimally invasive right colectomy in the obese patients: a multicenter propensity score-matched analysis

Despite the well-known benefits of the minimally invasive approach for the right colon cancer treatment, less is known about its feasibility and advantages in morbid obese patients. The aim of this study is to compare the postoperative outcomes after totally minimally invasive right colectomy between the obese and non-obese population. Data derived from a prospectively maintained multicenter colorectal database were analysed, dividing the enrolled patients into two groups: obese (BMI > 29.99) patient group and non-obese patient group. Data about gender, age, American Society of Anesthesiologists (ASA) Score, tumor characteristics, operative time, anastomosis time, extraction site, incision length, intraoperative complications, postoperative complications, postoperative recovery, specimen length and retrieved nodes were taken to assess the achievement of the oncologic standards. After a propensity score matching, a total of 184 patients was included, 92 in each group. No differences were found in terms of demographic data and tumor characteristics. Intraoperative data showed a significant difference in terms of anastomosis time in favour of non-obese group (p < 0.0001). No intraoperative complications were recorded and no conversion was needed in both groups. No differences were found in terms of postoperative complications. There were no differences in terms of first mobilization (p = 0.745), time to first flatus (p = 0.241) time to tolerance to liquid and solid diet (p = 0.241 and p = 0.06) and length of hospital stay (p = 0.817). The analysis of oncologic outcomes demonstrated adequate results in both groups. The results obtained by our study confirmed the feasibility and safety of the totally minimally invasive approach even in obese population.

Differences in effectiveness and use of laparoscopic surgery in locally advanced colon cancer patients

Patients with locally advanced colon cancer have worse outcomes. Guidelines of various organizations are conflicting about the use of laparoscopic colectomy (LC) in locally advanced colon cancer. We determined whether patient outcomes of LC and open colectomy (OC) for locally advanced (T4) colon cancer are comparable in all colon cancer patients, T4a versus T4b patients, obese versus non-obese patients, and tumors located in the ascending, descending, and transverse colon. We used data from the 2013–2015 American College of Surgeons’ National Surgical Quality Improvement Program. Patients were diagnosed with nonmetastatic pT4 colon cancer, with or without obstruction, and underwent LC (n = 563) or OC (n = 807). We used a composite outcome score (mortality, readmission, re-operation, wound infection, bleeding transfusion, and prolonged postoperative ileus); length of stay; and length of operation. Patients undergoing LC exhibited a composite outcome score that was 9.5% lower (95% CI − 15.4; − 3.5) versus those undergoing OC. LC patients experienced a 11.3% reduction in postoperative ileus (95% CI − 16.0; − 6.5) and an average of 2 days shorter length of stay (95% CI − 2.9; − 1.0). Patients undergoing LC were in the operating room an average of 13.5 min longer (95% CI 1.5; 25.6). We found no evidence for treatment heterogeneity across subgroups (p > 0.05). Patients with locally advanced colon cancer who receive LC had better overall outcomes and shorter lengths of stay compared with OC patients. LC was equally effective in obese/nonobese patients, in T4a/T4b patients, and regardless of the location of the tumor.

Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial

OBJECTIVE

To compare short-term perioperative outcomes of single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for colon cancer.

SUMMARY BACKGROUND DATA

Although many studies reported short- and long-term outcomes of SPLS for colon cancer compared with MPLS, few have reported results of randomized controlled trials.

METHODS

This was a multicenter, prospective, randomized controlled trial with a noninferiority design. It was conducted between August 2011 and June 2017 at 7 sites in Korea. A total of 388 adults (aged 19-85 yrs) with clinical stage I, II, or III adenocarcinoma of the ascending or sigmoid colon were enrolled and randomized. The primary endpoint was 30-day postoperative complication rates. Secondary endpoints were the number of harvested lymph nodes, length of the resection margin, postoperative pain, and time to functional recovery (bowel movement and diet). Patients were followed for 30 days after surgery.

RESULTS

Among 388 patients, 359 (92.5%) completed the study (SPLS, n = 179; MPLS, n = 180). The 30-day postoperative complication rate was 10.6% in the SPLS group and 13.9% in the MPLS group (95% confidence interval, -10.05 to 3.05 percentage points; P < 0.0001). Total incision length was shorter in the SPLS group than in the MPLS group (4.6 cm vs 7.2 cm, P < 0.001), whereas the length of the specimen extraction site did not differ (4.4 cm vs 4.6 cm, P = 0.249). There were no significant differences between groups for all secondary endpoints and all other outcomes.

CONCLUSIONS

Even though there was no obvious benefit to SPLS over MPLS when performing colectomy for cancer, our data suggest that SPLS is noninferior to MPLS and can be considered an option in selected patients, when performed by experienced surgeons.Trial registration: ClinicalTrials.gov Identifier: NCT01480128.

Systematic review of single-incision versus conventional multiport laparoscopic surgery for sigmoid colon and rectal cancer

Objectives

To explore whether single-incision laparoscopic surgery (SILS) has the better short-term clinical and pathological outcomes than conventional multiport laparoscopic surgery (CLS) for sigmoid colon and rectal cancer.

Methods

A literature investigation of MEDLINE, PubMed, Ovid, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chinese Biological Medicine (CBM), and Wanfang databases for relevant researches was performed. Fixed effects and random effects models were used to calculate the corresponding outcomes. Standardized mean difference and risk ratio were calculated for continuous and dichotomous variables separately.

Results

Nine clinical controlled trials were composed of two randomized clinical trials and seven non-randomized clinical trials with a total of 829 patients. Two hundred ninety-nine (36.1%) patients underwent SILS, and 530 (63.9%) patients underwent CLS. The meta-analysis showed that SILS had more lymph node resection (SMD − 0.25, 95% CI − 0.50 to − 0.002) and less defecation time (SMD − 0.46, 95% CI − 0.75 to − 0.17), exhaust time (SMD − 0.46, 95% CI − 0.75 to − 0.18), and hospital stay (SMD − 0.30, 95% CI − 0.45 to − 0.15 than CLS. SILS was also accompanied with shorter incision length (SMD − 2.46, 95% CI − 4.02 to − 0.90), less pain score (SMD − 0.56, 95% CI − 0.91 to − 0.21), and lower complication rate (RR 0.66, 95% CI 0.47 to 0.91). Blood loss, operative time, distal margin, conversion rate, anastomotic fistula, readmission, local recurrence, and distant metastasis showed no statistical differences in two groups. In all subgroup analysis, SILS also had advantages of incision length, operative time, defecation time, exhaust time, and hospitalization time than CLS.

Conclusion

SILS could be a more safe and reliable surgical technique than CLS for sigmoid colon and rectal cancer. However, further high-quality studies between these two techniques need to be further developed.

Thirty-Day Hospital Readmission After Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis for Chronic Ulcerative Colitis at a High-Volume Center

BACKGROUND

Ileal pouch anal anastomosis (IPAA) is associated with a high 30-day hospital readmission rate. Risk factors and etiology of readmission remain poorly defined. We sought to determine the 30-day hospital readmission rate following IPAA at a high-volume center and identify any modifiable perioperative factors.

METHODS

A retrospective review of all patients undergoing two- or three-stage IPAA for chronic ulcerative colitis at our institution between 2002 and 2013 was performed. Analysis was performed on rate of readmission, readmission diagnosis, intervention performed upon readmission, and risk factors for readmission.

RESULTS

Thirty-day primary and secondary readmission rates after IPAA were 20.3% (n = 185) and 2.1% (n = 19), respectively. The leading etiologies for readmission included partial small bowel obstruction/ileus (n = 52, 21.9%), pelvic sepsis (n = 43, 18.1%), dehydration (n = 42, 17.7%), and venous thromboembolism (n = 31, 13.1%). While the majority of readmissions were managed medically (n = 119, 65.4%), 19.2% (n = 35) required radiologic intervention and 15.3% (n = 28) required a return to the operating room. On univariate analysis, younger age (p = 0.03) and female sex (p = 0.04) had a significantly increased risk of readmission. On multivariable analysis, BMI ≥ 30 (OR 0.51; 95% CI, 0.25-0.97, p = 0.04) was protective of readmission.

CONCLUSIONS

Thirty-day hospital readmission following IPAA remains a common problem. Preventable etiologies of readmission include dehydration and venous thromboembolism (VTE). Future quality improvement efforts should focus on education regarding stoma output and extended VTE prophylaxis to decrease hospital readmission rates following IPAA.

Feasibility of laparoscopic partial nephrectomy in the obese patient and assessment of predictors of perioperative outcomes

Introduction:

Partial nephrectomy is the gold standard for treatment of small renal masses. Our study compares outcomes for obese (body mass index [BMI] ≥30) and healthy (BMI <30) patients undergoing laparoscopic partial nephrectomy (LPN) with the intention of defining preoperative risk factors for complications and renal insufficiency in the obese.

Materials and Methods:

We conducted a retrospective review of 187 consecutive patients who underwent LPN. We examined the association between BMI and postoperative complication, estimated blood loss (EBL), hospital length of stay, warm ischemic time (WIT), and postoperative renal function. We did similar analyses using the RENAL nephrometry score and the comorbidity status of the patients.

Results:

We found no statistically significant increase in complications in obese (BMI ≥30) individuals relative to healthy (BMI <30) patients. The obese experienced approximately 100 cc more EBL (P = 0.0111). Patients experienced more complications if they had a Charlson comorbidity score ≥3 (P = 0.0065), an American Association of Anesthesiologists score ≥3 (P = 0.0042), or a history of diabetes mellitus (P = 0.0196). There was no association between RENAL nephrometry score and complication. However, patients with a score ≥8 experienced higher WIT (P = 0.0022), a greater decline in estimated glomerular filtration rate postoperatively (P = 0.0488), and an increased risk of developing chronic kidney disease ≥3 (P = 0.0065).

Conclusions:

Obese patients undergoing LPN are not at significantly increased risk of complication relative to nonobese patients. Comorbidity status and RENAL nephrometry score, independent of BMI, should be the main considerations of a patient's suitability for LPN.

Predicting opportunities to increase utilization of laparoscopy for colon cancer

BACKGROUND

Despite proven safety and efficacy, rates of minimally invasive approaches for colon cancer remain low in the USA. Given the known benefits, investigating the root causes of underutilization and methods to increase laparoscopy is warranted. Our goal was to develop a predictive model of factors impacting use of laparoscopic surgery for colon cancer.

METHODS

The Premier Hospital Database was reviewed for elective colorectal resections for colon cancer (2009-2014). Patients were identified by ICD-9-CM diagnosis code and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes. An adjusted multivariate logistic regression model identified variables predictive of use of laparoscopy for colon cancer.

RESULTS

A total of 24,245 patients were included-12,523 (52 %) laparoscopic and 11,722 (48 %) open. General surgeons performed the majority of all procedures (77.99 % open, 71.60 % laparoscopic). Overall use of laparoscopy increased from 48.94 to 52.03 % over the study period (p < 0.0001). Patients with private insurance were more likely to have laparoscopy compared with Medicare patients (adjusted odds ratio (OR) 1.089, 95 % CI [1.004, 1.181], p = 0.0388). Higher volume of surgeons (OR 3.518, 95 % CI [2.796, 4.428], p < 0.0001) and larger hospitals by bed size were more likely to approach colon cancer laparoscopically. Colorectal surgeons were 32 % more likely to approach a case laparoscopically than general surgeons (OR 1.315, 95 % CI [1.222, 1.415], p < 0.0001). Teaching hospitals, hospitals in the Midwest, and hospitals with less than 500 beds were less likely to use laparoscopy.

CONCLUSIONS

There are patient, provider, and hospital characteristics that can be identified preoperatively to predict who will undergo surgery for colon cancer using laparoscopy. However, additional patients may be eligible for laparoscopy based on patient-level characteristics. These results have implications for regionalization and increasing teaching of MIS. Recognizing and addressing these variables with training and recruiting could increase use of minimally invasive approaches, with the associated clinical and financial benefits.

Effect of BMI on Short-Term Outcomes with Robotic-Assisted Laparoscopic Surgery: a Case-Matched Study

BACKGROUND

Many benefits of minimally invasive surgery are lost in the obese, but robotic-assisted laparoscopic surgery (RALS) may offer advantages in this population. Our goal was to compare outcomes for RALS in obese and non-obese patients.

METHODS

A prospective database was reviewed for colorectal resections using RALS. Patients were stratified into obese (BMI > 30 kg/m(2)) and non-obese cohorts (BMI < 30 kg/m(2)), then case-matched for comparability. The main outcome measures were operative time, conversion rate, length of stay and complication, readmission, and reoperation rates between groups.

RESULTS

Forty-five patients were evaluated in each cohort. The BMI was significantly different (p < 0.01). All other demographics were well matched. There were no significant differences in operative time (p = 0.86), blood loss (p = 0.38), intraoperative complications (p = 0.54), or conversion rates (p = 0.91) across cohorts. Length of stay was comparable between groups (p = 0.45). Postoperatively, the complication (p = 0.87), readmission (p = 1.00), and reoperation rates (p = 0.95) were similar. There were no mortalities. For malignant cases (37.8 %), the lymph node yield (p = 0.48) and positive margins (p = 1.00) were similar and acceptable in both cohorts.

CONCLUSIONS

In our matched RALS series, perioperative and postoperative outcomes were similar between obese and non-obese patients undergoing colorectal surgery. RALS is a feasible option in the surgical setting of the obese patient. Further controlled studies are warranted to explore the full benefits.

Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.