1
|
Delayed surgery after radio-chemotherapy for rectal adenocarcinoma is protective for anastomotic dehiscence: a single-center observational retrospective cohort study. Updates Surg 2020; 72:469-475. [PMID: 32306273 DOI: 10.1007/s13304-020-00770-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
Ideal time interval between end of neoadjuvant radio-chemotherapy (NRCT) and surgery for rectal cancer is debated. Effect that different time intervals have on postoperative complications with particular regard to anastomotic dehiscence (AD) was evaluated on 167 patients who underwent surgery after long-course NRCT. Three different time intervals were considered: (0-42; 43-56; > 57 days). A time interval > 57 days was significantly protective for AD (p = 0.04, Odds ratio = 0.35; 95% CI 0.1254-0.9585) without influence on early oncological outcomes. Optimal time interval after end of NRCT and surgery may help achieving the best pathological response with lowest postoperative morbidity.Trial registration number: Clinical Trial. Gov NCT04013347. https://clinicaltrials.gov/ct2/results?cond=&term=NCT04013347&cntry=&state=&city=&dist= ).
Collapse
|
2
|
Leraas HJ, Ong CT, Sun Z, Adam MA, Kim J, Gilmore BF, Ezekian B, Nag US, Mantyh CR, Migaly J. Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients. J Gastrointest Surg 2017; 21:684-691. [PMID: 28083836 DOI: 10.1007/s11605-016-3350-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/30/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Hand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique. METHODS We queried the 2012-2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach. RESULTS This query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p < 0.001), and total abdominal colectomy (OR 10.39, p < 0.001). Younger age, black race, ASA class ≥3, inflammatory bowel disease, and low pelvic anastomosis were predictive of OC (all p < 0.05). HALS demonstrated reduced overall complications (p < 0.001), wound complications (p < 0.001), anastomotic leak (p = 0.014), transfusion (p < 0.001), postoperative ileus (p < 0.001), length of stay (p < 0.001), and readmission (p < 0.001) without increased operative time. For segmental resection, HALS demonstrated reduced overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion, length of stay, and readmissions (all p < 0.05). CONCLUSIONS Compared to OC, HALS demonstrates improved perioperative outcomes without increased operative time.
Collapse
Affiliation(s)
- Harold J Leraas
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA.
| | - Cecilia T Ong
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Zhifei Sun
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Jina Kim
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Brian Ezekian
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Uttara S Nag
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - Christopher R Mantyh
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| | - John Migaly
- Department of Surgery, Duke University Medical Center, Box 3443, Durham, NC, 27710, USA
| |
Collapse
|
3
|
Cancer recurrence following conversion during laparoscopic colorectal resections: a meta-analysis. Aging Clin Exp Res 2017; 29:115-120. [PMID: 27854066 DOI: 10.1007/s40520-016-0674-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/03/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Evidence regarding long-term oncological outcomes following conversion to open surgery (COS) during laparoscopic colorectal resection (LCR) is controversial. The aim of this study is to assess the impact on cancer recurrence of a failed laparoscopic attempt. METHODS MEDLINE, Scopus and ISI Web of Knowledge databases were searched for articles reporting data on cancer recurrence in patients undergoing completed LCR and COS. Data were pooled by fixed or random effect modeling, according to the presence of heterogeneity. Primary outcomes were local recurrence (LR) and distance recurrence (DR). RESULTS Seven studies involving 2493 patients (completed LCR, n 2201 and COS, n 292) were included. The pooled analysis showed that COS resections have an higher risk of LR (OR 1.97, 95% CI 1.14-3.42, p = 0.1); no difference was found in DR (OR 1.09, 95% CI 0.67-1.77, p = 0.71). However, an higher rate of T4 tumor was present in the converted group (OR 2.62, 95% CI 1.71-4, p = 0.0). Subgroup analysis including studies with T stage matched populations showed no significant statistical difference in LR rate; however, a trend toward higher recurrence was still clear. CONCLUSION There is no consistent evidence that a failed laparoscopic attempt does not result in a poorer oncological outcome; therefore, a careful selection of patients for LCR for cancer is required.
Collapse
|
4
|
Massarotti H, Rodrigues F, O'Rourke C, Chadi SA, Wexner S. Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery. Colorectal Dis 2017; 19:76-85. [PMID: 27234928 DOI: 10.1111/codi.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/16/2016] [Indexed: 12/19/2022]
Abstract
AIM The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery. METHOD An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C). RESULTS In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity. CONCLUSION Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.
Collapse
Affiliation(s)
- H Massarotti
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - F Rodrigues
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - C O'Rourke
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S A Chadi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| |
Collapse
|
5
|
Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon's experience: a cost analysis covering the initial 50 robotic cases with the da Vinci Si. Int J Colorectal Dis 2016; 31:1639-48. [PMID: 27475091 DOI: 10.1007/s00384-016-2631-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study is to compare surgical parameters and the costs of robotic surgery with those of laparoscopic approach in rectal cancer based on a single surgeon's early robotic experience. METHODS Data from 25 laparoscopic (LapTME) and the first 50 robotic (RobTME) rectal resections performed at our institution by an experienced laparoscopic surgeon (>100 procedures) between 2009 and 2014 were retrospectively analyzed and compared. Patient demographic, procedure, and outcome data were gathered. Costs of the two procedures were collected, differentiated into fixed and variable costs, and analyzed against the robotic learning curve according to the cumulative sum (CUSUM) method. RESULTS Based on CUSUM analysis, RobTME group was divided into three phases (Rob1: 1-19; Rob2: 20-40; Rob3: 41-50). Overall median operative time (OT) was significantly lower in LapTME than in RobTME (270 vs 312.5 min, p = 0.006). A statistically significant change in OT by phase of robotic experience was detected in the RobTME group (p = 0.010). Overall mean costs associated with LapTME procedures were significantly lower than with RobTME (p < 0.001). Statistically significant reductions in variable and overall costs were found between robotic phases (p < 0.009 for both). With fixed costs excluded, the difference between laparoscopic and Rob3 was no longer statistically significant. CONCLUSIONS Our results suggest a significant optimization of robotic rectal surgery's costs with experience. Efforts to reduce the dominant fixed cost are recommended to maintain the sustainability of the system and benefit from the technical advantages offered by the robot.
Collapse
|
6
|
Colorectal surgery in a rural setting. Updates Surg 2015; 67:407-19. [DOI: 10.1007/s13304-015-0331-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/21/2015] [Indexed: 01/27/2023]
|
7
|
Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies. Surg Endosc 2015; 30:1629-34. [PMID: 26275534 DOI: 10.1007/s00464-015-4393-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/01/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD). PURPOSE To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis. METHODS Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively. RESULTS Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications. CONCLUSIONS Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.
Collapse
|
8
|
Tam MS, Kaoutzanis C, Mullard AJ, Regenbogen SE, Franz MG, Hendren S, Krapohl G, Vandewarker JF, Lampman RM, Cleary RK. A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc 2015; 30:455-463. [PMID: 25894448 DOI: 10.1007/s00464-015-4218-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.
Collapse
Affiliation(s)
- Michael S Tam
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA
| | - Christodoulos Kaoutzanis
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA
| | - Andrew J Mullard
- Michigan Surgical Quality Collaborative, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael G Franz
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA
| | - Samantha Hendren
- Division of Colorectal Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Greta Krapohl
- Michigan Surgical Quality Collaborative, University of Michigan Health System, Ann Arbor, MI, USA
| | - James F Vandewarker
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA
| | - Richard M Lampman
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA
| | - Robert K Cleary
- Division of Colorectal Surgery, Department of Surgery, Saint Joseph Mercy Health System, 5333 McAuley Drive, Suite 2111, Ann Arbor, MI, 48106, USA.
| |
Collapse
|