Impact of minimally invasive surgery on short-term outcomes after rectal resection for neoplasm within the setting of an enhanced recovery program

Low Anterior Resection Syndrome following Restorative Proctectomy for Rectal Cancer: Can the Surgeon Have Any Meaningful Impact?

Postoperative bowel dysfunction following restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long term sequela of rectal cancer treatment. While many of the established risk factors for LARS are non-modifiable, others may be well within the surgeon's control. Several pre-, intra-, and postoperative decisions may have a significant impact on postoperative bowel function. Some of these factors include the extent of surgical resection, surgical approach, choice of anastomotic reconstruction, and use of fecal diversion. This review article summarizes the available evidence regarding how surgical decision-making can affect postoperative bowel function.

Have outcomes following colectomy in the United States improved over time?

BACKGROUND

There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale.

METHODS

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses.

RESULTS

261,301 patients, 135,876 (52 ​%) female, with a median age of 62 (IQR 53-72) were included. Across all years, MIS partial colectomy was the most common procedure (37 ​%), followed by MIS low anterior resection (27 ​%), open partial colectomy (24 ​%), and open low anterior resection (12 ​%). MIS increased from 59 ​% in 2012-2014 to 66 ​% in 2018-2020 (p ​< ​0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4-7) in 2012-2014 to 4 days (IQR 3-6) in 2018-2020 (p ​< ​0.001). Superficial surgical site infections decreased from 5.5 ​% in 2012-2014 to 2.9 ​% in 2018-2020 (p ​< ​0.001). Deep surgical site infections similarly decreased from 1.1 ​% to 0.4 ​% between these periods (p ​< ​0.001). Pulmonary embolism also decreased from 0.6 ​% to 0.5 ​% between periods (p ​= ​0.02). 30-day mortality was unchanged at 1.7 ​% between 2012-2014 and 2018-2020 (p ​= ​0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 ​% decrease in postoperative length of stay (p ​< ​0.001).

CONCLUSIONS

Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally.

Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer

BACKGROUND

Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown.

OBJECTIVE

This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy.

DESIGN

This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included.

MAIN OUTCOME MEASURES

Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery.

RESULTS

A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014).

LIMITATIONS

The study was limited by its retrospective and nonrandomized before-and-after design.

CONCLUSIONS

Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

The prevalence of venous thromboembolism in rectal surgery: a systematic review and meta-analysis

PURPOSE

Venous thromboembolism (VTE) following rectal surgery is a significant and preventable cause of morbidity and mortality, yet the true prevalence is not well established. This systematic review and meta-analysis assessed the available literature and determined its prevalence following rectal surgery.

METHODS

A systematic review assessed the prevalence of VTE following rectal surgery. In addition, we evaluated whether subgroups (open vs. minimally invasive or benign vs. malignant resections) impacted on its prevalence or rate of deep venous thrombosis (DVT) or pulmonary embolism (PE).

RESULT

Thirty-eight studies met the predefined inclusion criteria. The aggregate prevalence of VTE following rectal surgery was 1.25% (95% CI 0.86-1.63), with DVT and PE occurring in 0.68% (95% CI 0.48-0.89) and 0.57% (95% CI 0.47-0.68) of patients. VTE following cancer and benign resection was 1.59% (95% CI 0.60-1.23 and 1.5% (95% CI 0.89-2.12) respectively. The prevalence of VTE in patients having minimally invasive resection was lower than those having open surgery [0.58% (16/2770) vs. 2.22% (250/11278); RR 0.54, 95% CI 0.33-0.86].

CONCLUSION

This review observed that there is sparse evidence on prevalence of VTE following rectal surgery. It provides aggregated data and analysis of available literature, showing overall prevalence is low, especially in those having minimally invasive procedures.

Factors Influencing Length of Stay after Elective Bowel Resection within an Enhanced Recovery Protocol

A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.