The Learning Curve for the Laparoscopic Approach for Colorectal Cancer: A Single Institution's Experience

Has the open surgical approach in colorectal cancer really become uncommon?

Colorectal cancer is the third most common cancer in the world. Surgery is mandatory to treat patients with colorectal cancer. Can colorectal cancer be treated in laparoscopy? Scientific literature has validated the oncological quality of laparoscopic approach for the treatment of patients with colorectal cancer. Randomized non-inferiority trials with good remote control have answered positively to this long-debated question. Early as 1994, first publications demonstrated technical feasibility and compliance with oncological imperatives and, as far as short-term outcomes are concerned, there is no difference in terms of mortality and post-operative morbidity between open and minimally invasive surgical approaches, but only longer operating times at the beginning of the experience. Subsequently, from 2007 onwards, long-term results were published that demonstrated the absence of a significant difference regarding overall survival, disease-free survival, quality of life, local and distant recurrence rates between open and minimally invasive surgery. In this editorial, we aim to summarize the clinical and technical aspects which, even today, make the use of open surgery relevant and necessary in the treatment of patients with colorectal cancer.

Is natural orifice specimen extraction surgery the future direction of minimally invasive colorectal surgery?

As science and technology have advanced, surgical techniques have become increasingly sophisticated. A revolution was triggered by the appearance of new electrical and optical instruments, shifting the field of surgery in the direction of "minimally invasive" and "noninvasive" procedures. Natural orifice specimen extraction surgery has emerged as a rising star in the field of minimally invasive surgery. It has increased rapidly, and it has become a hot topic in recent years. Natural orifice specimen extraction surgery has shown advantages in alleviating postoperative pain, improving bowel movements, providing a cosmetic effect, and improving psychological state without adversely affecting cancer outcomes. Different approaches have been classified and summarized for natural orifice specimen extraction surgery based on the procedure for specimen extraction and the location of the tumor, and natural orifice specimen extraction surgery can be used in resection all parts of the colorectum. The international natural orifice specimen extraction surgery consensus and monograph have also been published to improve the standardization of the application of this technique. Additional steps need to be taken to standardize natural orifice specimen extraction surgery, such as conducting large-scale randomized controlled trials, establishing a training system, and developing specific tools. Still, the natural orifice specimen extraction surgery procedure continues to follow the development of minimally invasive surgery and may be one of the future treatment options.

Change point analysis validation of the learning curve in laparoscopic colorectal surgery: Experience from a non-structured training setting

BACKGROUND

The introduction of minimal invasive principles in colorectal surgery was a major breakthrough, resulting in multiple clinical benefits, at the cost, though, of a notably steep learning process. The development of structured nation-wide training programs led to the easier completion of the learning curve; however, these programs are not yet universally available, thus prohibiting the wider adoption of laparoscopic colorectal surgery.

AIM

To display our experience in the learning curve status of laparoscopic colorectal surgery under a non-structured training setting.

METHODS

We analyzed all laparoscopic colorectal procedures performed in the 2012-2019 period under a non-structured training setting. Cumulative sum analysis and change-point analysis (CPA) were introduced.

RESULTS

Overall, 214 patients were included. In terms of operative time, CPA identified the 110^th case as the first turning point. A plateau was reached after the 145^th case. Subgroup analysis estimated the 58^th for colon and 52^nd case for rectum operations as the respective turning points. A learning curve pattern was confirmed for pathology outcomes, but not in the conversion to open surgery and morbidity endpoints.

CONCLUSION

The learning curves in our setting validate the comparability of the results, despite the absence of National or Surgical Society driven training programs.

Mentor Tutoring: An Efficient Method for Teaching Laparoscopic Colorectal Surgical Skills in a General Hospital

OBJECTIVE

We retrospectively assessed the efficacy of our mentor tutoring system for teaching laparoscopic colorectal surgical skills in a general hospital.

MATERIALS AND METHODS

A series of 55 laparoscopic colectomies performed by 1 trainee were evaluated. Next, the learning curves for high anterior resection performed by the trainee (n=20) were compared with those of a self-trained surgeon (n=19).

RESULTS

Cumulative sum analysis and multivariate regression analyses showed that 38 completed cases were needed to reduce the operative time. In high anterior resection, the mean operative times were significantly shorter after the seventh average for the tutored surgeon compared with that for the self-trained surgeon. In cumulative sum charting, the curve reached a plateau by the seventh case for the tutored surgeon, but continued to increase for the self-trained surgeon.

CONCLUSIONS

Mentor tutoring effectively teaches laparoscopic colorectal surgical skills in a general hospital setting.

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Attaining surgical competency and its implications in surgical clinical trial design: a systematic review of the learning curve in laparoscopic and robot-assisted laparoscopic colorectal cancer surgery

BACKGROUND

Laparoscopic surgery is increasingly used in the treatment of colorectal cancer and more recently robotic assistance has been advocated. However, the learning curve to achieve surgical proficiency in laparoscopic surgery is ill-defined and subject to many influences. The aim of this review was to comprehensively appraise the literature on the learning curve for laparoscopic and robotic colorectal cancer surgery, and to quantify attainment of surgical proficiency and its implications in surgical clinical trial design.

METHODS

A systematic review using a defined search strategy was performed. Included studies had to state an explicit numerical value of the learning curve evaluated by a single parameter or multiple parameters.

RESULTS

Thirty-four studies were included, 28 laparoscopic and 6 robot assisted. Of the laparoscopic studies, nine defined the learning curve on the basis of a single parameter. Nine studies used more than one parameter to define learning, and 11 used a cumulative sum (CUSUM) analysis. One study used both a multiparameter and CUSUM analysis. The definition of proficiency was subjective, and the number of operations to achieve it ranged from 5 to 310 cases for laparoscopic and 15-30 cases for robotic surgery.

CONCLUSIONS

The learning curve in laparoscopic colorectal surgery is multifaceted and often ill-defined, with poor descriptions of mentorship/supervision. Further, the quantification to attain proficiency is variable. The use of a single parameter to quantify this is simplistic. Multidimensional assessment is recommended; as part of this, the CUSUM model, which assesses trends in multiple surgical outcomes, is useful and appropriate when assessing the learning curve in a clinical setting.