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Marks JH, Keller DS, Lagares-Garcia JA, Schoonyoung HP, Farritor SM, Oleynikov D, Jobst MA. Safety and Efficacy of a Novel Miniaturized Robotic-Assisted Surgery System in Colectomy: A Prospective, Investigational Device Exemption Clinical Study Using the IDEAL Framework. Dis Colon Rectum 2024; 67:1085-1093. [PMID: 38653496 PMCID: PMC11250098 DOI: 10.1097/dcr.0000000000003249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Robotics has increased rates of minimally invasive surgery, with distinct advantages over open surgery. However, current commercially available robotic platforms have device and system issues that limit robotic-assisted surgery expansion. OBJECTIVE To demonstrate the safety and efficacy of a novel miniaturized robotic-assisted surgery device in colectomy. DESIGN Prospective, Investigational Device Exemption clinical study following the idea, development, exploration, assessment, and long-term follow-up framework (stage 2b, exploration). SETTINGS Three centers with high-volume robotic colorectal cases and surgeons. PATIENTS Patients scheduled for a right or left colectomy for benign or malignant disease. INTERVENTION Colectomy with the novel miniaturized robotic-assisted surgery device. MAIN OUTCOME MEASURES For safety, intraoperative and device-related adverse events and 30-day morbidity. For efficacy, successful completion of predefined procedural steps without conversion. RESULTS Thirty patients (13 women, 17 men) were analyzed. The mean age was 59.4 (SD 13.4) years. Seventy percent of patients (n = 21) were overweight/obese and 53.3% of patients (n = 16) had prior abdominal surgery. Forty percent of patients had malignant and 60% had benign disease. Cases were 15 right and 15 left colectomies. Overall operative time was a median of 146 (range, 80-309) minutes; console time was 70 (range, 34-174) minutes. There were no conversions to open surgery and no intraoperative or device-related adverse events. In 100% of patients (n = 30), the primary dissection was completed, and hemostasis was maintained with the novel miniaturized robotic-assisted surgery device. The morbidity rate was 26.7% minor and 3.3% major. The median length of stay was 2 days. There were no mortalities. LIMITATIONS Single-arm study, short-term follow-up. CONCLUSIONS This first clinical study of a novel miniaturized robotic-assisted surgery device along the IDEAL framework demonstrated that it was safe and effective. Given this success, further assessment and long-term follow-up of the miniaturized robotic-assisted surgery device are planned for comparative clinical and economic effectiveness in colorectal surgery. See Video Abstract . SEGURIDAD Y EFICACIA DE UN NOVEDOSO SISTEMA DE CIRUGA ASISTIDA POR ROBOT MINIATURIZADO EN COLECTOMA UN ESTUDIO CLNICO PROSPECTIVO DE INVESTIGACIN DE EXENCIN DE DISPOSITIVO QUE UTILIZA EL MARCO IDEAL ANTECEDENTES:La robótica ha aumentado las tasas de cirugía mínimamente invasiva, con claras ventajas sobre la cirugía abierta. Sin embargo, las plataformas robóticas actualmente disponibles comercialmente tienen problemas con los dispositivos y sistemas que limitan la expansión de la cirugía asistida por robot.OBJETIVO:Demostrar la seguridad y eficacia de un novedoso dispositivo de cirugía asistida por robot miniaturizado en colectomía.DISEÑO:Estudio clínico prospectivo de investigación de exención de dispositivo siguiendo el marco IDEAL (Etapa 2b, exploración).ESCENARIO:Tres centros con cirujanos y casos colorrectales robóticos de gran volumen.PACIENTES:Pacientes programados para colectomía derecha o izquierda por enfermedad benigna o maligna.INTERVENCIÓN:Colectomía con el nuevo dispositivo de cirugía asistida por robot miniaturizado.PRINCIPALES MEDIDAS DE RESULTADO:Para la seguridad, eventos adversos intraoperatorios y relacionados con el dispositivo y morbilidad a 30 días. Para la evaluación de la eficacia, la finalización exitosa de los pasos predefinidos sin conversión.RESULTADOS:Se analizaron treinta pacientes (13 mujeres, 17 hombres). La edad media fue 59,4 (DE 13,4) años. El 70% (n=21) tenía sobrepeso/obesidad y el 53,3% (n=16) había tenido cirugía abdominal previa. El 40% tenía enfermedad maligna y el 60% benigna. Los casos fueron 15 colectomías derechas y 15 izquierdas. La mediana del tiempo operatorio general fue de 146 (rango, 80-309) minutos; 70 (rango, 34-174) minutos fue el tiempo de consola. No hubo conversiones a cirugía abierta ni eventos adversos intraoperatorios o relacionados con el dispositivo. En el 100% (n=30), se completó la disección primaria y se mantuvo la hemostasia con el novedoso dispositivo de cirugía asistida por robot miniaturizado. La tasa de morbilidad menor fue de un 26,7% y mayor un 3,3%. La mediana de estadía fue de 2 días. No hubo mortalidad.LIMITACIONES:Estudio de un solo brazo, corto plazo de seguimiento.CONCLUSIONES:Este primer estudio clínico de un novedoso dispositivo de cirugía asistida por robot miniaturizado según el marco IDEAL demostró que era seguro y eficaz. Dado este éxito, se planean evaluaciones adicionales y seguimiento a largo plazo del dispositivo de cirugía asistida por robot miniaturizado para comparar la efectividad clínica y económica en la cirugía colorrectal. (Traducción-Dr. Felipe Bellolio ).
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Affiliation(s)
- John H. Marks
- Marks Colorectal Surgical Associates, Department of Surgery, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Deborah S. Keller
- Marks Colorectal Surgical Associates, Department of Surgery, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Jorge A. Lagares-Garcia
- Division of Colon and Rectal Surgery, Department of Surgery, Roper St. Francis Health Alliance, Charleston, South Carolina
| | - Henry P. Schoonyoung
- Marks Colorectal Surgical Associates, Department of Surgery, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Shane M. Farritor
- Department of Mechanical Engineering, University of Nebraska, Lincoln, Nebraska
| | - Dmitry Oleynikov
- Department of Surgery, Monmouth Medical Center, Robert Wood Johnson and Barnabas Health, Long Branch, New Jersey
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Bonatti HJR. Experience with Laparoscopic and Robotic Colon Surgery Together with Other Major Minimally Invasive Procedures for Unrelated Pathologies. J Laparoendosc Adv Surg Tech A 2024; 34:556-560. [PMID: 38531046 DOI: 10.1089/lap.2024.0072] [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] [Indexed: 03/28/2024] Open
Abstract
Background: Indications for combined colon surgery together with other procedures include oncologic multivisceral resections and abdominal trauma. It is unclear if combining minimally invasive (MI) colon surgery with unrelated other procedures increases the risk for complications. Patients and Methods: The surgical database from two institutions during a 10-year period was queried for combined colon surgeries together with other interventions. All open cases, combined cases performed for one pathology and MI colectomies together with a minor procedure, were excluded. Results: Median age of the 6 men and 7 women was 64.4 (range 42.7-75.4) years. Colon surgeries included right (5), sigmoid (4) transverse (1) colectomies, rectum resection (1), rectopexy (1), and colostomy reversal (1) with indications of colorectal cancer (5), diverticulitis (3), benign ileocecal mass (1), colonic volvulus (3) and rectal prolapse (1). Second procedures included two splenectomies (sarcoidosis, ITP), paraesophageal hernia repairs (4), right diaphragmatic repairs [eventration (2) and Morgagni type hernia]; cholecystectomies (2), appendectomy (acute appendicitis), duodenal wedge resection (carcinoid), reversal of a gastric bypass (Roux limb stricture) one each. Cases were done laparoscopically (7) and robotic assisted (6). In most cases only 4 trocars were used. Median OR time was 4.3 (range 2.5 to 6.6) hours. No anastomotic breakdown was observed. Conclusions: Combining MI colectomy and other major abdominal surgeries can be safely done and in this series did not increase morbidity or mortality but avoids a second operation. Patient selection seems important and port placement may need to be altered to achieve good exposure for both procedures.
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Affiliation(s)
- Hugo J R Bonatti
- Meritus Surgical Specialists, Meritus Health, Hagerstown, Maryland, USA
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Horesh N, Emile SH, Garoufalia Z, Gefen R, Zhou P, Wexner SD. Upfront laparotomy versus conversion from minimally invasive surgery to open surgery in colon cancer: Is there a difference in outcomes? Surgery 2024; 176:69-75. [PMID: 38641543 DOI: 10.1016/j.surg.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/12/2024] [Accepted: 03/08/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND It is unclear whether conversion from minimally invasive surgery to laparotomy in patients with colon cancer contributes to worse outcomes compared with those operated by laparotomy. In this study, we aimed to assess the implications of transitioning from minimally invasive surgery to laparotomy in patients with colon cancer compared with patients undergoing upfront laparotomy. METHODS A retrospective analysis of the National Cancer Database, including patients with stages I to III colon cancer (2010-2019). Patients who underwent either upfront laparotomy (Open Surgery Group) or minimally invasive surgery converted to open surgery (Converted Surgery Group) were included. Groups were balanced using propensity-score matching. Primary outcome was overall survival, and secondary outcomes included 30- and 90-day mortality and 30-day readmission rates. RESULTS The study included 65,083 operated patients with stage I to III colon cancer; 57,091 patients (87.7%) were included in the Open Surgery group and 7,992 (12.3%) in the Converted Surgery group. 93.5% were converted from laparoscopy, and 6.5% were converted from robotic surgery. After propensity-score matching, 7,058 patients were included in each group. Median overall survival was significantly higher in the Converted Surgery group (107.3 months) than in the Open Surgery group (101.5 months; P = .006). A survival benefit was seen in patients >65 years of age (79.5 vs 71.9 months; P = .001), left-sided disease (129.4 vs 114.5 months; P < .001), and with a high Charlson comorbidity index score (=3; 58.9 vs 42.3 months; P = .03). Positive margin rates were similar between the groups (6.3% vs 5.6%; P = .07). Converted patients had a higher 30-day readmission rate (6.7% vs 5.6%, P = .006) and shorter duration of stay (median, 5 vs 6 days, P < .001) than patients in the Open Surgery group. In addition, 30-day mortality was comparable between the groups (2.9% vs 3.5%; P = .07). CONCLUSION Conversion to open surgery from minimally invasive surgery was associated with better overall survival compared with upfront open surgery. A survival benefit was mainly seen in patients >65 years of age, with significant comorbidities, and with left-sided tumors. We believe these data suggest that, in the absence of an absolute contraindication to minimally invasive surgery, it should be the preferred approach in patients with colon cancer.
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Affiliation(s)
- Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Affiliated with the Faculty of Medicine, Tel Aviv University, Israel. https://www.twitter.com/nirhoresh
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University, Faculty of Medicine, Egypt. https://www.twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://www.twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel. https://www.twitter.com/RachellGefen
| | - Peige Zhou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Georgia Colon and Rectal Surgical Associates, Northside Hospital, Atlanta, GA. https://www.twitter.com/PZhou_MD
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [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] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Abernethy EK, Aly EH. Postoperative Ileus after Minimally Invasive Colorectal Surgery: A Summary of Current Strategies for Prevention and Management. Dig Surg 2024; 41:79-91. [PMID: 38359801 PMCID: PMC11025667 DOI: 10.1159/000537805] [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: 04/19/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS. SUMMARY Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies. KEY MESSAGES Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.
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Affiliation(s)
| | - Emad H Aly
- University of Aberdeen, Aberdeen, UK
- Aberdeen Royal Infirmary, Aberdeen, UK
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Balas M, Quereshy F, Bohnen J, Jung JJ. Early Discharge after Uncomplicated Elective Colectomy and Risk of Postdischarge Complication. J Am Coll Surg 2024; 238:182-196. [PMID: 37909537 DOI: 10.1097/xcs.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND This was a retrospective cohort study of adult patients undergoing uncomplicated elective colectomy using the NSQIP database from January 2012 to December 2019. A colectomy is deemed uncomplicated if there are no complications reported during the hospitalization. The objective of this study was to examine the association between discharge timing and postdischarge complications in patients who undergo uncomplicated elective colectomy. STUDY DESIGN Patients were stratified into an early discharge group if their length of postoperative hospitalization was ≤3 days for laparoscopic or robotic approaches, or ≤5 days for the open approach, and otherwise into delayed discharge groups. The association between early discharge and any postdischarge complication was examined using unadjusted logistic regression after propensity score matching between early and delayed discharge groups. RESULTS Of the 113,940 patients included, 77,979, 15,877, and 20,084 patients underwent uncomplicated laparoscopic, robotic, and open colectomy, respectively. After propensity score matching, the odds of a postdischarge complication were lower for the early discharge group in laparoscopic (odds ratio 0.73, 95% CI 0.68 to 0.79) and robotic (odds ratio 0.63, 95% CI 0.52 to 0.76) approaches, and not different in the open approach (odds ratio 1.02, 95% CI 0.91 to 1.15). There were no clinically meaningful differences in the risk of return to the operating room for all surgical approaches. CONCLUSIONS Early discharge after uncomplicated colectomy appears to be safe and is associated with lower odds of postdischarge complications in minimally invasive approaches. Our findings suggest that surgical teams practice sound clinical judgments on selecting patients who benefit from early discharge.
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Affiliation(s)
- Michael Balas
- From the Temerty Faculty of Medicine (Balas, Quereshy, Jung), University of Toronto, Toronto, ON, Canada
| | - Fayez Quereshy
- From the Temerty Faculty of Medicine (Balas, Quereshy, Jung), University of Toronto, Toronto, ON, Canada
- Department of Surgery (Quereshy, Jung), University of Toronto, Toronto, ON, Canada
| | - Jordan Bohnen
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA (Bohnen)
| | - James J Jung
- From the Temerty Faculty of Medicine (Balas, Quereshy, Jung), University of Toronto, Toronto, ON, Canada
- Department of Surgery (Quereshy, Jung), University of Toronto, Toronto, ON, Canada
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Ahuja V, Paredes LG, Leeds IL, Perkal MF, Tsutsumi A, Bhandarkar S, King JT. Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches. Am J Surg 2024; 227:85-89. [PMID: 37806892 PMCID: PMC10842593 DOI: 10.1016/j.amjsurg.2023.09.038] [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: 06/30/2023] [Revised: 09/05/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND We sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement. METHODS We queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression. RESULTS We identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P < 0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03-1.08, P = 0.005) than their White LC counterparts and RC patients. CONCLUSIONS Robotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.
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Affiliation(s)
- Vanita Ahuja
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Lucero G Paredes
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Maine Medical Center, Portland, ME, USA
| | - Ira L Leeds
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Melissa F Perkal
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ayaka Tsutsumi
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Joseph T King
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, USA; Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
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Rein LKL, Dohrn N, Gögenur I, Falk Klein M. Robotic versus laparoscopic approach for left-sided colon cancer: a nationwide cohort study. Colorectal Dis 2023; 25:2366-2377. [PMID: 37919465 DOI: 10.1111/codi.16803] [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: 01/09/2023] [Revised: 05/16/2023] [Accepted: 07/16/2023] [Indexed: 11/04/2023]
Abstract
AIM The use of robot-assisted surgery for left-sided colon cancer is increasing in Denmark; however, it is yet to be established if the robotic approach results in improved clinical outcomes compared with the corresponding laparoscopic approach. The aim of this study was to compare the intraoperative and short-term postoperative outcomes of robot-assisted surgery with laparoscopic surgery for left-sided colon cancer at a national level. METHOD The study is a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centres in Denmark treated with surgery with curative intent in an elective setting with either robotic or laparoscopic left colectomy or sigmoidectomy during the period 2014-2019 were included. To adjust for confounding, propensity score matching (PSM) was performed and the groups were compared for age, sex, body mass index, American Society of Anesthesiologists classification, performance score, year of diagnosis, neoadjuvant chemotherapy, left colectomy or sigmoidectomy, tumour localization, use of stoma or stenting and pathological T (pT) category. RESULTS A total of 5532 patients were available for analysis, and after PSM in a ratio of 2:1, 1392 laparoscopic and 696 robotic cases were identified. After matching we found a lower conversion rate and a higher lymph node yield in the robotic group compared with the laparoscopic group (5.8% vs. 11%, p < 0.001 and 27 vs. 24, p < 0.001, respectively). Further, we found a higher proportion of patients with a lymph node yield of 12 or more in the robotic group (97% vs. 94.8%, p = 0.02). Plane of dissection, radicality and pathological disease stages did not differ between the two groups. We found no difference in either overall surgical (13% vs. 11.1%, p = 0.23) or medical (5.6% vs. 6.5%, p = 0.49) postoperative complications and no difference in 30-day (p = 0.369) or 90-day mortality (p = 0.08). CONCLUSION Robot-assisted surgery for left-sided colon cancer was associated with a significantly lower conversion rate and a significantly higher lymph node yield than the laparoscopic approach. Postoperative morbidity and mortality were similar in the two groups.
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Affiliation(s)
| | - Niclas Dohrn
- Department of Surgery, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Mads Falk Klein
- Department of Surgery, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Solis-Pazmino P, Oka K, La K, Termeie O, Ponce O, Figueroa L, Weston A, Machry M, Cohen J, Barnajian M, Nasseri Y. Robotic right versus left colectomy for colorectal neoplasia: a systemic review and meta-analysis. J Robot Surg 2023; 17:1907-1915. [PMID: 37310528 DOI: 10.1007/s11701-023-01649-0] [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] [Received: 04/16/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
Previous studies comparing right and left colectomies have shown variable short-term outcomes. Despite the rapid adoption of robotics in colorectal operations, few studies have addressed outcome differences between robotic right (RRC) and left (RLC) colectomies. Therefore, we sought to compare the short-term outcomes of RRC and RLC for neoplasia. This is a systematic review and meta-analysis of articles published from the time of inception of the datasets to May 1, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus. A total of 13,514 patients with colon neoplasia enrolled in 9 comparative studies were included. The overall mean age was 64.1 years (standard deviation [SD] ± 9.8), and there was a minor female predominance (52% female vs. 48% male). 8656 (64.0%) underwent RRC and 4858 (36.0%) underwent RLC. The ASA score 1 of - 2 in the LRC group was 37% vs. 21% in the R. Whereas the ASA score 3-4 was 62% in the LRC vs. 76% in RRC. Moreover, the mean of the Charlson Comorbidity Score in the LRC was 4.3 (SD 1.9) vs. 3.1 (SD 2.3) in the RRC. Meta-analysis revealed a significantly higher rate of ileus in RRC (10%) compared to RLC (7%) (OR 1.46, 95% CI 1.27-1.67). Additionally, operative time was significantly shorter by 22.6 min in RRC versus LRC (95% CI - 37.4-7.8; p < 0.001). There were no statistically significant differences between RRC and RLC in conversion to open operation, estimated blood loss, wound infection, anastomotic leak, reoperation, readmission, and hospital length of stay. In this only meta-analysis comparing RRC and LRC for colon neoplasia, we found that RRC was independently associated with a shorter operative time but increased risk of ileus.
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Affiliation(s)
- Paola Solis-Pazmino
- Surgery Group Los Angeles, Los Angeles, CA, USA.
- Surgery Department, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil.
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, 55905, USA.
- CaTaLiNA-Cancer de Tiroides en Latino America, Quito, Ecuador.
| | | | - Kristina La
- Surgery Group Los Angeles, Los Angeles, CA, USA
| | | | - Oscar Ponce
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, 55905, USA
- CaTaLiNA-Cancer de Tiroides en Latino America, Quito, Ecuador
| | - Luis Figueroa
- CaTaLiNA-Cancer de Tiroides en Latino America, Quito, Ecuador
- Facultad de Ciencias Médicas, Universidad Central del Ecuador, Quito, Ecuador
| | - Antonio Weston
- Surgery Department, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil
| | - Mayara Machry
- Surgery Department, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil
| | - Jason Cohen
- Surgery Group Los Angeles, Los Angeles, CA, USA
| | | | - Yosef Nasseri
- Surgery Group Los Angeles, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Solaini L, Giuliani G, Cavaliere D, Bocchino A, Di Marino M, Avanzolini A, Coratti A, Ercolani G. Robotic versus laparoscopic left colectomy: a propensity score matched analysis from a bi-centric experience. J Robot Surg 2023; 17:2135-2140. [PMID: 37247120 PMCID: PMC10492709 DOI: 10.1007/s11701-023-01634-7] [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: 01/18/2023] [Accepted: 05/21/2023] [Indexed: 05/30/2023]
Abstract
The advantages of using the robotic platform may not be clearly evident in left colectomies, where the surgeon operates in an "open field" and does not routinely require intraoperative suturing. Current evidences are based on limited cohorts reporting conflicting outcomes regarding robotic left colectomies (RLC). The aim of this study is to report a bi-centric experience with robotic left colectomy in order to help in defining the role of the robotic approach for these procedures. This is a bi-centric propensity score matched study including patients who underwent RLC or laparoscopic left colectomy (LLC) between January 1, 2012 and May 1, 2022. RLC patients were matched to LLC patients in a 1:1 ratio. Main outcomes were conversion to open surgery and 30-day morbidity. In total, 300 patients were included. Of 143 (47.7%) RLC patients, 119 could be matched. After matching, conversion rate (4.2 vs. 7.6%, p = 0.265), 30-day morbidity (16.1 vs. 13.7%, p = 0.736), Clavien-Dindo grade ≥ 3 complications (2.4 vs 3.2%, p = 0.572), transfusions (0.8 vs. 4.0%, p = 0.219), and 30-day mortality (0.8 vs 0.8%, p = 1.000) were comparable for RLC and LLC, respectively. Median operative time was longer for RLC (296 min 260-340 vs. 245, 195-296, p < 0.0001). Early oral feeding, time to first flatus, and hospital stay were similar between groups. RLC has safety parameters as well as conversion to open surgery comparable with standard laparoscopy. Operative time is longer with the robotic approach.
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Affiliation(s)
- Leonardo Solaini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
- General and Oncologic Surgery, Morgagni Pierantoni Hospital, Ausl Romagna, Via c. Forlanini 34, Forlì, Italy.
| | - Giuseppe Giuliani
- Department of General and Emergency Surgery, Misericordia Hospital, Azienda Usl Toscana Sud Est, Grosseto, Italy
| | - Davide Cavaliere
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Bocchino
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- General and Oncologic Surgery, Morgagni Pierantoni Hospital, Ausl Romagna, Via c. Forlanini 34, Forlì, Italy
| | - Michele Di Marino
- Department of General and Emergency Surgery, Misericordia Hospital, Azienda Usl Toscana Sud Est, Grosseto, Italy
| | - Andrea Avanzolini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Andrea Coratti
- Department of General and Emergency Surgery, Misericordia Hospital, Azienda Usl Toscana Sud Est, Grosseto, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- General and Oncologic Surgery, Morgagni Pierantoni Hospital, Ausl Romagna, Via c. Forlanini 34, Forlì, Italy
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11
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Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Baldazzi G, Scatizzi M. Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts. Int J Surg 2023; 109:2312-2323. [PMID: 37195782 PMCID: PMC10442086 DOI: 10.1097/js9.0000000000000480] [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] [Received: 03/08/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. MATERIALS AND METHODS A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026). CONCLUSION The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.
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Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Rome
- General Surgery Unit, “C.&G. Mazzoni” Hospital, Ascoli Piceno
| | | | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella (VR)
| | - Massimo G. Viola
- General Surgery Unit, Cardinale G. Panico Hospital, Tricase (LE)
| | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO)
- General & Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo
| | - Gianandrea Baldazzi
- General Surgery Unit, ASST Ovest Milanese, Legnano (MI)
- General Surgery Unit, ASST Nord Milano, Sesto San Giovanni (MI)
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Firenze, Italy
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12
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Bastawrous AL, Shih IF, Li Y, Khalil M, Almaz B, Cleary RK. Health-care expenditures are less for minimally invasive than open colectomy for colon cancer: A US commercial claims database analysis. Surg Endosc 2023:10.1007/s00464-023-10104-y. [PMID: 37193891 PMCID: PMC10338385 DOI: 10.1007/s00464-023-10104-y] [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: 11/14/2022] [Accepted: 04/23/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Most studies comparing surgical platforms focus on short-term outcomes. In this study, we compare the expanding societal penetration of minimally invasive surgery (MIS) with open colectomy by assessing payer and patient expenditures up to one year for patients undergoing surgery for colon cancer. METHODS We analyzed the IBM MarketScan Database for patients who underwent left or right colectomy for colon cancer between 2013 and 2020. Outcomes included perioperative complications and total health-care expenditures up to 1 year following colectomy. We compared results for patients who had open colectomy (OS) to those with MIS operations. Subgroup analyses were performed for adjuvant chemotherapy (AC+) versus no adjuvant chemotherapy (AC-) groups and for laparoscopic (LS) versus robotic (RS) approaches. RESULTS Of 7,063 patients, 4,417 cases did not receive adjuvant chemotherapy (OS: 20.1%, LS: 67.1%, RS: 12.7%) and 2646 cases had adjuvant chemotherapy (OS: 28.4%, LS: 58.7%, RS: 12.9%) after discharge. MIS colectomy was associated with lower mean expenditure at index surgery and post-discharge periods for AC- patients (index surgery: $34,588 vs $36,975; 365-day post-discharge $20,051 vs $24,309) and for AC+ patients (index surgery: $37,884 vs $42,160; 365-day post-discharge $103,341vs $135,113; p < 0.001 for all comparisons). LS had similar index surgery expenditures but significantly higher expenditures at post-discharge 30 days (AC-: $2,834 vs $2276, p = 0.005; AC+: $9100 vs $7698, p = 0.020) than RS. The overall complication rate was significantly lower in the MIS group than the open group for AC- patients (20.5% vs 31.2%) and AC+ patients (22.6% vs 39.1%, both p < 0.001). CONCLUSION MIS colectomy is associated with better value at lower expenditure than open colectomy for colon cancer at the index operation and up to one year after surgery. RS expenditure is less than LS in the first 30 postoperative days regardless of chemotherapy status and may extend to 1 year for AC- patients.
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Affiliation(s)
| | - I-Fan Shih
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc, Sunnyvale, CA, USA
| | - Yanli Li
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc, Sunnyvale, CA, USA
| | - Marissa Khalil
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Biruk Almaz
- Swedish Cancer Institute, Swedish Health System, Seattle, WA, USA
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106, USA.
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Serra-Aracil X, Mora-Lopez L, Gomez-Torres I, Pallisera-Lloveras A, Serracant A, Garcia-Nalda A, Pino-Perez O, Torrecilla A, Navarro-Soto S. Laparoscopic and robotic intracorporeal resection and end-to-end anastomosis in left colectomy: a prospective cohort study - stage 2a IDEAL framework for evaluating surgical innovation. Langenbecks Arch Surg 2023; 408:135. [PMID: 37002506 PMCID: PMC10065998 DOI: 10.1007/s00423-023-02844-1] [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] [Received: 08/19/2022] [Accepted: 02/16/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To analyze the safety and feasibility of intracorporeal resection and anastomosis in upper rectum, sigmoid, and left colon surgery, via both laparoscopic and robotic approaches. The secondary aim was to assess possible short-term differences between laparoscopic versus robotic surgery. METHODS A prospective observational cohort study according to IDEAL framework exploration and assessment stage (Development, stage 2a), evaluating and comparing the laparoscopic approach and the robotic approach in left colon, sigmoid, and upper rectum surgery with intracorporeal resection and end-to-end anastomosis. Demographic, preoperative, surgical, and postoperative variables of patients undergoing laparoscopic and robotic surgery are described and compared according to the surgical technique used. RESULTS Between May 2020 and March 2022, seventy-nine patients were consecutively included in the study, 41 operated via laparoscopy (laparoscopic left colectomy: LLC) and 38 by robotic surgery (robotic left colectomy: RLC). There were no statistically significant differences between the two groups in terms of demographic variables. In surgical variables, the median surgical times differed significantly: 198 min (SD 48 min) for LLC vs. 246 min (SD 72 min) for RLC (p = 0.01, 95% CI: - 75.2 to - 20.5)). The only significant difference regarding postoperative complications was a higher degree of relevant morbidity in the LLC (Clavien-Dindo > II (14.6% vs. 0%, p = 0.03) and Comprehensive Complication Index (IQR 22 vs. IQR 0, p = 0.03). The pathological results were similar in both approaches. CONCLUSION Laparoscopic and robotic intracorporeal resection and anastomosis are feasible and safe, and obtain similar surgical, postoperative, and pathological results than described in literature. However, morbidity seems to be higher in LLC group with fewer relevant postoperative complications. The results of this study enable us to proceed to stage 2b of the IDEAL framework. CLINICAL TRIAL REGISTRATIONS The study is registered in Clinical trials with the registration code NCT0445693.
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Affiliation(s)
- X Serra-Aracil
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain.
- Coloproctology Unit, General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain.
| | - L Mora-Lopez
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - I Gomez-Torres
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - A Pallisera-Lloveras
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - A Serracant
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - A Garcia-Nalda
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - O Pino-Perez
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - A Torrecilla
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
| | - S Navarro-Soto
- Unidad de Coloproctología, Servicio de Cirugía General Y del Ap. Digestivo, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Universitat Autònoma de Barcelona, Parc Tauli S/N, 08208, Sabadell (Barcelona), Spain
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14
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McKechnie T, Khamar J, Daniel R, Lee Y, Park L, Doumouras AG, Hong D, Bhandari M, Eskicioglu C. The Senhance Surgical System in Colorectal Surgery: A Systematic Review. J Robot Surg 2022; 17:325-334. [PMID: 36127508 DOI: 10.1007/s11701-022-01455-0] [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: 08/25/2022] [Accepted: 09/08/2022] [Indexed: 10/14/2022]
Abstract
The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m2) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I2 = 0%), console time of 141.3 min (95% CI 106.5-176.1, I2 = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I2 = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I2 = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ryan Daniel
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lily Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Division of General Surgery, Department of Surgery, McMaster University. St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Division of General Surgery, Department of Surgery, McMaster University. St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Mohit Bhandari
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada. .,Division of General Surgery, Department of Surgery, McMaster University. St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
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15
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Right colectomy from open to robotic - a single-center experience with functional outcomes in a learning-curve setting. Langenbecks Arch Surg 2022; 407:2915-2927. [PMID: 35678902 PMCID: PMC9640414 DOI: 10.1007/s00423-022-02576-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/29/2022] [Indexed: 12/03/2022]
Abstract
Purpose Right colectomy (RC) is a frequently performed procedure. Beneath standard conventional open surgery (COS), various minimally invasive techniques had been introduced. Several advantages had recently been described for robotic approaches over COS or conventional laparoscopy. Nevertheless, novel minimally invasive techniques require continuous benchmarking against standard COS to gain maximum patient safety. Bowel dysfunction is a frequent problem after RC. Together with general complication rates postoperative bowel recovery are used as surrogate parameters for postoperative patient outcome in this study. Methods Retrospective, 10-year single-center analysis of consecutive patients who underwent sequentially either COS (n = 22), robotic-assisted (ECA: n = 39), or total robotic surgery (ICA: n = 56) for oncologic RC was performed. Results The conversion from robotic to open surgery rate was low (overall: 3.2%). Slightly longer duration of surgery had been observed during the early phase after introduction of the robotic program to RC (ECA versus COS, p = 0.044), but not anymore thereafter (versus ICA). No differences were observed in oncologic parameters including rates of tumor-negative margins, lymph node-positive patients, and lymph node yield during mesocolic excision. Both robotic approaches are beneficial regarding postoperative complication rates, especially wound infections, and shorter length of in-hospital stay compared with COS. The duration until first postoperative stool is the shortest after ICA (COS: 4 [2–8] days, ECA: 3 [1–6] days, ICA: 3 [1–5] days, p = 0.0004). Regression analyses reveal neither a longer duration of surgery nor the extent of mesocolic excision, but the degree of minimally invasiveness and postoperative systemic inflammation contribute to postoperative bowel dysfunction, which prolongs postoperative in-hospital stay significantly. Conclusion The current study reflects the institutional learning curve of oncologic RC during implementation of robotic surgery from robotic-assisted to total robotic approach without compromises in oncologic results and patient safety. However, the total robotic approach is beneficial regarding postoperative bowel recovery and general patient outcome.
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Ricciardi R, Goldstone RN, Francone T, Wszolek M, Auchincloss H, de Groot A, Shih IF, Li Y. Healthcare Resource Utilization After Surgical Treatment of Cancer: Value of Minimally Invasive Surgery. Surg Endosc 2022; 36:7549-7560. [PMID: 35445834 PMCID: PMC9022614 DOI: 10.1007/s00464-022-09189-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 12/24/2022]
Abstract
Background As the US healthcare system moves towards value-based care, hospitals have increased efforts to improve quality and reduce unnecessary resource use. Surgery is one of the most resource-intensive areas of healthcare and we aim to compare health resource utilization between open and minimally invasive cancer procedures. Methods We retrospectively analyzed cancer patients who underwent colon resection, rectal resection, lobectomy, or radical nephrectomy within the Premier hospital database between 2014 and 2019. Study outcomes included length of stay (LOS), discharge status, reoperation, and 30-day readmission. The open surgical approach was compared to minimally invasive approach (MIS), with subgroup analysis of laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and robotic (RS) approaches, using inverse probability of treatment weighting. Results MIS patients had shorter LOS compared to open approach: − 1.87 days for lobectomy, − 1.34 days for colon resection, − 0.47 days for rectal resection, and − 1.21 days for radical nephrectomy (all p < .001). All MIS procedures except for rectal resection are associated with higher discharge to home rates and lower reoperation and readmission rates. Within MIS, robotic approach was further associated with shorter LOS than LAP/VATS: − 0.13 days for lobectomy, − 0.28 days for colon resection, − 0.67 days for rectal resection, and − 0.33 days for radical nephrectomy (all p < .05) and with equivalent readmission rates. Conclusion Our data demonstrate a significant shorter LOS, higher discharge to home rate, and lower rates of reoperation and readmission for MIS as compared to open procedures in patients with lung, kidney, and colorectal cancer. Patients who underwent robotic procedures had further reductions in LOS compare to laparoscopic/video-assisted thoracoscopic approach, while the reductions in LOS did not lead to increased rates of readmission. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09189-8.
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Affiliation(s)
- Rocco Ricciardi
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA.
| | - Robert Neil Goldstone
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA
| | - Todd Francone
- Section of Colon & Rectal Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 460, Boston, MA, USA
| | - Matthew Wszolek
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hugh Auchincloss
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander de Groot
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
| | - I-Fan Shih
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
| | - Yanli Li
- Global Access, Value, & Economics, Intuitive Surgical, Sunnyvale, CA, USA
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17
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Solaini L, Bocchino A, Avanzolini A, Annunziata D, Cavaliere D, Ercolani G. Robotic versus laparoscopic left colectomy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1497-1507. [PMID: 35650261 PMCID: PMC9262793 DOI: 10.1007/s00384-022-04194-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to review the new evidence to understand whether the robotic approach could find some clear indication also in left colectomy. METHODS A systematic review of studies published from 2004 to 2022 in the Web of Science, PubMed, and Scopus databases and comparing laparoscopic (LLC) and robotic left colectomy (RLC) was performed. All comparative studies evaluating robotic left colectomy (RLC) versus laparoscopic (LLC) left colectomy with at least 20 patients in the robotic arm were included. Abstract, editorials, and reviews were excluded. The Newcastle-Ottawa Scale for cohort studies was used to assess the methodological quality. The random-effect model was used to calculate pooled effect estimates. RESULTS Among the 139 articles identified, 11 were eligible, with a total of 52,589 patients (RLC, n = 13,506 versus LLC, n = 39,083). The rate of conversion to open surgery was lower for robotic procedures (RR 0.5, 0.5-0.6; p < 0.001). Operative time was longer for the robotic procedures in the pooled analysis (WMD 39.1, 17.3-60.9, p = 0.002). Overall complications (RR 0.9, 0.8-0.9, p < 0.001), anastomotic leaks (RR 0.7, 0.7-0.8; p < 0.001), and superficial wound infection (RR 3.1, 2.8-3.4; p < 0.001) were less common after RLC. There were no significant differences in mortality (RR 1.1; 0.8-1.6, p = 0.124). There were no differences between RLC and LLC with regards to postoperative variables in the subgroup analysis on malignancies. CONCLUSIONS Robotic left colectomy requires less conversion to open surgery than the standard laparoscopic approach. Postoperative morbidity rates seemed to be lower during RLC, but this was not confirmed in the procedures performed for malignancies.
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Affiliation(s)
- Leonardo Solaini
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy ,grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Antonio Bocchino
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Andrea Avanzolini
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Domenico Annunziata
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Davide Cavaliere
- grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Giorgio Ercolani
- grid.6292.f0000 0004 1757 1758Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy ,grid.415079.e0000 0004 1759 989XGeneral and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
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Diaz SE, Lee YF, Bastawrous AL, Shih IF, Lee SH, Li Y, Cleary RK. Comparison of health-care utilization and expenditures for minimally invasive vs. open colectomy for benign disease. Surg Endosc 2022; 36:7250-7258. [PMID: 35194661 PMCID: PMC9485164 DOI: 10.1007/s00464-022-09097-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/07/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Adoption of minimally invasive approaches continues to increase, and there is a need to reassess outcomes and cost. We aimed to compare open versus minimally invasive colectomy short- and long-term health-care utilization and payer/patient expenditures for benign disease. METHODS This is a retrospective analysis of IBM® MarketScan® Database patients who underwent left or right colectomy for benign disease between 2013 and 2018. Outcomes included total health-care expenditures, resource utilization, and direct workdays lost up to 365 days following colectomy. The open surgical approach (OS) was compared to minimally invasive colectomy (MIS) with subgroup analysis of laparoscopic (LS) and robotic (RS) approaches using inverse probability of treatment weighting. RESULTS Of 10,439 patients, 2531 (24.3%) had open, 6826 (65.4%) had laparoscopic, and 1082 (10.3%) had robotic colectomy. MIS patients had shorter length of stay (LOS; mean difference, - 1.71, p < 0.001) and lower average total expenditures (mean difference, - $2378, p < 0.001) compared with open patients during the index hospitalization. At 1 year, MIS patients had lower readmission rates, and fewer mean emergency and outpatient department visits than open patients, translating into additional savings of $5759 and 2.22 fewer days missed from work for health-care visits over the 365-day post-discharge period. Within MIS, RS patients had shorter LOS (mean difference, - 0.60, p < 0.001) and lower conversion-to-open rates (odds ratio, 0.31 p < 0.001) during the index hospitalization, and lower hospital outpatient visits (mean difference, - 0.31, p = 0.001) at 365 days than LS. CONCLUSION MIS colectomy is associated with lower mean health-care expenditures and less resource utilization compared to the open approach for benign disease at index operation and 365-days post-discharge. Health-care expenditures for LS and RS are similar but shorter mean LOS and lower conversion-to-open surgery rates were observed at index operation for the RS approach.
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Affiliation(s)
- Sarah E. Diaz
- grid.416444.70000 0004 0370 2980Department of Surgery, St Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI 48106 USA
| | - Yongjin F. Lee
- grid.281044.b0000 0004 0463 5388Swedish Cancer Institute, Seattle, WA USA
| | - Amir L. Bastawrous
- grid.281044.b0000 0004 0463 5388Swedish Cancer Institute, Seattle, WA USA
| | - I.-Fan Shih
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Shih-Hao Lee
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Yanli Li
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Robert K. Cleary
- grid.416444.70000 0004 0370 2980Department of Surgery, St Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI 48106 USA
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