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Shah MF, Nasir IUI, Ahmad R, Ahmad S, Amjad A, Zaineb KB, Rehman R. Short-Term Outcomes of First 100 Laparoscopic Colorectal Surgeries at a Newly Developed Surgical Setup at Peshawar. Cureus 2024; 16:e53588. [PMID: 38449997 PMCID: PMC10915358 DOI: 10.7759/cureus.53588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) has risen steadily, necessitating innovative strategies for diagnosis and treatment. Minimally invasive surgery, exemplified by laparoscopic techniques, has emerged as a transformative approach in colorectal surgical practices. Laparoscopy offers advantages such as improved aesthetic outcomes, reduced post-operative pain, early patient mobilization, and shorter hospital stays. OBJECTIVE This study aims to present the short-term surgical outcomes of the first 100 elective laparoscopic CRC resections performed at a newly established tertiary care cancer center in Peshawar, Pakistan. MATERIALS AND METHODS Data were prospectively collected for CRC resections performed between April 2021 and February 2022. The study included patients above 18 years of age with biopsy-proven CRC. Surgical procedures were performed by two dedicated colorectal surgeons trained in minimally invasive surgery. Patient demographics, pre-operative factors, intraoperative parameters, and post-operative outcomes were systematically recorded and analyzed. RESULTS Among the 100 cases included in the study, laparoscopic colorectal surgeries were successfully performed without any conversions to open surgery. The mean age of the study population was 52.5 years, with a male-to-female ratio of 2:1. The majority of cases were colon (48%) and anorectal cancers (52%). The mean lymph node yield was 18.29 (range 6-49). Only one patient required a re-look laparoscopy for a pelvic hematoma, and overall mortality was reported at 1%. CONCLUSION Laparoscopic colorectal surgery is a safe and effective treatment option for elective colorectal operations with minimal post-operative complications and favorable short-term outcomes.
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Affiliation(s)
- Muhammad F Shah
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Irfan Ul Islam Nasir
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Riaz Ahmad
- Colorectal Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Sajjad Ahmad
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Aalia Amjad
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Khush Bakht Zaineb
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Romana Rehman
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
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Gkionis IG, Flamourakis ME, Tsagkataki ES, Kaloeidi EI, Spiridakis KG, Kostakis GE, Alegkakis AK, Christodoulakis MS. Multidimensional analysis of the learning curve for laparoscopic colorectal surgery in a regional hospital: the implementation of a standardized surgical procedure counterbalances the lack of experience. BMC Surg 2020; 20:308. [PMID: 33267802 PMCID: PMC7709341 DOI: 10.1186/s12893-020-00975-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique. Methods From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 – group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups. Results There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083). Conclusions Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.
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Affiliation(s)
- Ioannis G Gkionis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece.
| | - Mathaios E Flamourakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni S Tsagkataki
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni I Kaloeidi
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Konstantinos G Spiridakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Georgios E Kostakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | | | - Manousos S Christodoulakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
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Alawfi H, Kim HS, Yang SY, Kim NK. Robotics Total Mesorectal Excision Up To the Minute. Indian J Surg Oncol 2020; 11:552-564. [PMID: 33281399 PMCID: PMC7714834 DOI: 10.1007/s13193-020-01109-3] [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: 02/24/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022] Open
Abstract
Surgical techniques have evolved over the past few decades, and minimally invasive surgery has been rapidly adapted to become a preferred operative approach for treating colorectal diseases. However, many of the procedures remain a technical challenge for surgeons to perform laparoscopically, which has prompted the development of robotic platforms. Robotic surgery has been introduced as the latest advance in minimally invasive surgery. The present article provides an overview of robotic rectal surgery and describes many advances that have been made in the field over the past two decades. More specifically, the introduction of the robotic platform and its benefits, and the limitations of current robotic technology, are discussed. Although the main advantages of robotic surgery over conventional laparoscopy appear to be lower conversion rates and better surgical specimen quality, oncological and functional outcomes appear to be similar to those of other alternatives. Other potential benefits include earlier recovery of voiding and sexual function after robotic total mesorectal excision. Nevertheless, the costs and lack of haptic feedback remain the primary limitations to the widespread use of robotic technology in the field.
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Affiliation(s)
| | - Ho Seung Kim
- Department of Surgery, Division of Colorectal Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722 Korea
| | - Seung Yoon Yang
- Department of Surgery, Division of Colorectal Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722 Korea
| | - Nam Kyu Kim
- Department of Surgery, Division of Colorectal Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722 Korea
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Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol 2020; 17:414-429. [PMID: 32203400 DOI: 10.1038/s41575-020-0275-y] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 02/07/2023]
Abstract
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Centre, New York, NY, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS); University College London, London, UK.
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Zhao Y, Hou XL, Ding JH, Zhao K, Xu X, Dong GL. Early Urinary Dysfunction after Laparoscopic Rectal Cancer Surgery: Does Surgeons’ Learning Curve Matter? Am Surg 2018. [DOI: 10.1177/000313481808400516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Poor early urinary outcomes after laparoscopy were reported in studies comparing laparoscopic versus open rectal cancer surgery. One possible explanation was that these studies might include a number of patients on the laparoscopic surgeons’ learning curve. This study aims to evaluate whether the learning curve of laparoscopic rectal cancer surgery influences early postoperative urinary dysfunction. Between September 2009 and December 2014, 208 consecutive patients undergoing laparoscopic rectal resection for rectal cancer were enrolled in the present study. All the clinical data were obtained from a prospectively compiled database. The primary outcomes were the incidences of postoperative urinary retention (POUR) and major urinary dysfunction requiring long-term urinary catheterization. POUR and major urinary dysfunction rate were 20.2 per cent (42/208) and 4.3 per cent (9/208), respectively. The learning curve analysis for operative time using the moving average method showed stabilization at 80 cases. Surgeon experience was divided into two periods: learning curve period (1–80 cases) and experienced period (81–208 cases). Multivariate analysis showed that older age (OR = 3.250, P = 0.006) and learning curve (OR = 2.241, P = 0.024) were independent risk factors for POUR. Learning curve was not significantly associated with increased rates of major urinary dysfunction (OR = 3.378, P = 0.092). Learning curve is a significant risk factor for increased rate of POUR after laparoscopic rectal cancer surgery. Technical training may be key to shorten the learning curve and limit its impact on the postoperative urinary complications.
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Affiliation(s)
- Yong Zhao
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
- Department of Colorectal Surgery, the General Hospital of the PLA Rocket Force, Beijing, China; and the
| | - Xiao-Ling Hou
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jian-Hua Ding
- Department of Colorectal Surgery, the General Hospital of the PLA Rocket Force, Beijing, China; and the
| | - Ke Zhao
- Department of Colorectal Surgery, the General Hospital of the PLA Rocket Force, Beijing, China; and the
| | - Xiao Xu
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
| | - Guang-Long Dong
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China
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Zanguie M, Abdollahi A, Salek R, Jangjoo A, Jabbari Nooghabi M, Shabahang H, Golmohammadzadeh H. Three Anastomotic Techniques Following Laparoscopic Rectal Cancer Resection: Our Experience in 155 Patients. Surg Innov 2017; 25:57-61. [DOI: 10.1177/1553350617745976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Mahtab Zanguie
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abbas Abdollahi
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Roham Salek
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Jangjoo
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Jabbari Nooghabi
- Department of Statistics, Faculty of Mathematical Sciences, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Hosein Shabahang
- Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Golmohammadzadeh
- Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Keller DS, Qiu J, Senagore AJ. Predicting opportunities to increase utilization of laparoscopy for rectal cancer. Surg Endosc 2017; 32:1556-1563. [PMID: 28917020 DOI: 10.1007/s00464-017-5844-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite proven safety and efficacy, rates of laparoscopy for rectal cancer in the US are low. With reports of inferiority with laparoscopy compared to open surgery, and movements to develop accredited centers, investigating utilization and predictors of laparoscopy are warranted. Our goal was to evaluate current utilization and identify factors impacting use of laparoscopic surgery for rectal cancer. METHODS The Premier™ Hospital Database was reviewed for elective inpatient rectal cancer resections (1/1/2010-6/30/2015). Patients were identified by ICD-9-CM diagnosis codes, and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes or billing charge. Logistic multivariable regression identified variables predictive of laparoscopy. The Cochran-Armitage test assessed trend analysis. The main outcome measures were trends in utilization and factors independently associated with use of laparoscopy. RESULTS 3336 patients were included-43.8% laparoscopic (n = 1464) and 56.2% open (n = 1872). Use of laparoscopy increased from 37.6 to 55.3% during the study period (p < 0.0001). General surgeons performed the majority of all resections, but colorectal surgeons were more likely to approach rectal cancer laparoscopically (41.31 vs. 36.65%, OR 1.082, 95% CI [0.92, 1.27], p < 0.3363). Higher volume surgeons were more likely to use laparoscopy than low-volume surgeons (OR 3.72, 95% CI [2.64, 5.25], p < 0.0001). Younger patients (OR 1.49, 95% CI [1.03, 2.17], p = 0.036) with minor (OR 2.13, 95% CI [1.45, 3.12], p < 0.0001) or moderate illness severity (OR 1.582, 95% CI [1.08, 2.31], p < 0.0174) were more likely to receive a laparoscopic resection. Teaching hospitals (OR 0.842, 95% CI [0.710, 0.997], p = 0.0463) and hospitals in the Midwest (OR 0.69, 95% CI [0.54, 0.89], p = 0.0044) were less likely to use laparoscopy. Insurance status and hospital size did not impact use. CONCLUSIONS Laparoscopy for rectal cancer steadily increased over the years examined. Patient, provider, and regional variables exist, with hospital status, geographic location, and colorectal specialization impacting the likelihood. However, surgeon volume had the greatest influence. These results emphasize training and surgeon-specific outcomes to increase utilization and quality in appropriate cases.
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Affiliation(s)
- Deborah S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, Baylor University Medical Center, 3500 Gaston Street, R-1013, Dallas, TX, 75246, USA.
| | - Jiejing Qiu
- Healthcare Economics and Outcomes Research, Medtronic, Mansfield, MA, USA
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Abstract
It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.
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Affiliation(s)
- Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
INTRODUCTION Robotic-assisted rectal cancer surgery offers multiple advantages for surgeons, and it seems to yield the same clinical outcomes as regards the short-time follow-up of patients compared to conventional laparoscopy. This surgical approach emerges as a technique aiming at overcoming the limitations posed by rectal cancer and other surgical fields of difficult access, in order to obtain better outcomes and a shorter learning curve. MATERIAL AND METHODS A systematic review of the literature of robot-assisted rectal surgery was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in October 2015 in PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials, for articles published in the last 10 years and pertaining the learning curve of robotic surgery for colorectal cancer. It consisted of the following key words: "rectal cancer/learning curve/robotic-assisted laparoscopic surgery". RESULTS A total of 34 references were identified, but only 9 full texts specifically addressed the analysis of the learning curve in robot-assisted rectal cancer surgery, 7 were case series and 2 were non-randomised case-comparison series. Eight papers used the cumulative sum (CUSUM) method, and only one author divided the series into two groups to compare both. The mean number of cases for phase I of the learning curve was calculated to be 29.7 patients; phase II corresponds to a mean number 37.4 patients. The mean number of cases required for the surgeon to be classed as an expert in robotic surgery was calculated to be 39 patients. CONCLUSION Robotic advantages could have an impact on learning curve for rectal cancer and lower the number of cases that are necessary for rectal resections.
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