1
|
Contrera KJ, Patel MR, Burtness B, Mehra R, Ferris RL. The role of surgery and deescalation for HPV-related oropharyngeal cancer. Cancer 2024. [PMID: 38497569 DOI: 10.1002/cncr.35287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Recently published and ongoing trials are helping to define the role of transoral robotic surgery for oropharyngeal cancer. Evidence to date supports the use of surgery as a valuable tool in the multidisciplinary deescalation of low-risk human papillomavirus-related oropharyngeal squamous cell carcinoma.
Collapse
Affiliation(s)
| | - Mihir R Patel
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Barbara Burtness
- Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Ranee Mehra
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | | |
Collapse
|
2
|
Grüter AAJ, Toorenvliet BR, Belgers EHJ, Belt EJT, van Duijvendijk P, Hoff C, Hompes R, Smits AB, van de Ven AWH, van Westreenen HL, Bonjer HJ, Tanis PJ, Tuynman JB. Nationwide standardization of minimally invasive right hemicolectomy for colon cancer and development and validation of a video-based competency assessment tool (the Right study). Br J Surg 2024; 111:znad404. [PMID: 38103184 PMCID: PMC10763527 DOI: 10.1093/bjs/znad404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Substantial variation exists when performing a minimally invasive right hemicolectomy (MIRH) due to disparities in training, expertise and differences in implementation of innovations. This study aimed to achieve national consensus on an optimal and standardized MIRH technique for colon cancer and to develop and validate a video-based competency assessment tool (CAT) for MIRH. METHOD Statements covering all elements of MIRH were formulated. Subsequently, the Delphi technique was used to reach consensus on a standardized MIRH among 76 colorectal surgeons from 43 different centres. A CAT was developed based on the Delphi results. Nine surgeons assessed the same 12 unedited full-length videos using the CAT, allowing evaluation of the intraclass correlation coefficient (ICC). RESULTS After three Delphi rounds, consensus (≥80% agreement) was achieved on 23 of the 24 statements. Consensus statements included the use of low intra-abdominal pressure, detailed anatomical outline how to perform complete mesocolic excision with central vascular ligation, the creation of an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision using a wound protector. The CAT included seven consecutive steps to measure competency of the MIRH and showed high consistency among surgeons with an overall ICC of 0.923. CONCLUSION Nationwide consensus on a standardized and optimized technique of MIRH was reached. The CAT developed showed excellent interrater reliability. These achievements are crucial steps to an ongoing nationwide quality improvement project (the Right study).
Collapse
Affiliation(s)
- Alexander A J Grüter
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Eric H J Belgers
- Department of Surgery, Zuyderland Medisch Centrum, Heerlen, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - Christiaan Hoff
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Anke B Smits
- Department of Surgery, St.Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | | | | | - Hendrik J Bonjer
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Ye SP, Lu WJ, Liu DN, Yu HX, Wu C, Xu HC, Li TY. Comparison of short-term efficacy analysis of medium-rectal cancer surgery with robotic natural orifice specimen extraction and robotic transabdominal specimen extraction. BMC Surg 2023; 23:336. [PMID: 37940918 PMCID: PMC10634172 DOI: 10.1186/s12893-023-02216-y] [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: 06/01/2023] [Accepted: 10/04/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND With the development of minimally invasive technology, the trauma caused by surgery get smaller, At the same time, the specimen extraction surgery through the natural orifice is more favored by experts domestically and abroad, robotic surgery has further promoted the development of specimen extraction surgery through the natural orifice. The aim of current study is to compare the short-term outcomes of robotic-assisted natural orifice specimen extraction (NOSES ) and transabdominal specimen extraction(TRSE ) in median rectal cancer surgery. METHODS From January 2020 to January 2023, 87 patients who underwent the NOSES or TRSE at the First Affiliated Hospital of Nanchang University were included in the study, 4 patients were excluded due to liver metastasis. Of these, 50 patients were in the TRSE and 33 patients in the NOSES. Short-term efficacy was compared in the two groups. RESULTS The NOSES group had less operation time (P < 0.001), faster recovery of gastrointestinal function (P < 0.001), shorter abdominal incisions (P < 0.001), lower pain scores(P < 0.001). lower Inflammatory indicators of the white blood cell count and C-reactive protein content at 1, 3, and 5 days after surgery (P < 0.001, P = 0.037). There were 9 complications in the NOSES group and 11 complications in the TRSE group(P = 0.583). However, there were no wound complications in the NOSES group. The number of postoperative hospital stays seems to be same in the two groups. And there was no significant difference in postoperative anus function (P = 0.591). CONCLUSIONS This study shows that NOSES and TRSE can achieve similar radical treatment effects, NOSES is a feasible and safe way to take specimens for rectal cancer surgery in accordance with the indication for NOSES.
Collapse
Affiliation(s)
- Shan-Ping Ye
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Wei-Jie Lu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Dong-Ning Liu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Hong-Xin Yu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Can Wu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Hao-Cheng Xu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China
| | - Tai-Yuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwaizheng Street, Nanchang, 330006, Jiangxi Province, China.
| |
Collapse
|
4
|
Yang WF, Chen W, He Z, Wu Z, Liu H, Li G, Li WL. Simple transanal total mesorectal resection versus laparoscopic transabdominal total mesorectal resection for the treatment of low rectal cancer: a single-center retrospective case-control study. Front Surg 2023; 10:1171382. [PMID: 37576920 PMCID: PMC10413134 DOI: 10.3389/fsurg.2023.1171382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Aim To evaluate the efficacy and safety of simple TaTNE in the treatment of low rectal cancer compared with laparoscopic transabdominal TME. Methods We collected patients with low rectal cancer admitted to our hospital between January 2019 and November 2021 who received simple TaTME or laparoscopic transabdominal TME. The main outcome was the integrity of the TME specimen. Secondary outcomes were the number of lymph nodes dissected, intraoperative blood loss, operative time, surgical conversion rate, Specimen resection length, circumferential margin (CRM), and distal resection margin (DRM), complication rate. In addition, the Wexner score and LARS score of fecal incontinence were performed in postoperative follow-up. Results Pathological tissues were successfully resected in all patients. all circumferential margins of the specimen were negative. Specimen resection length was not statistically significant (9.94 ± 2.85 vs. 8.90 ± 2.49, P > 0.05). The incidence of postoperative complications in group A (n = 0) was significantly lower than that in group B (n = 3) (P > 0.05). There was no significant difference in operation time between group A and group B (296 ± 60.36 vs. 305 ± 58.28, P > 0.05). Among the patients with follow-up time less than 1 year, there was no significant difference in Wexner score and LARS score between group A and group B (P > 0.05). However, in patients who were followed up for more than 1 year, the Wexner score in group A (9.25 ± 2.73) was significantly lower than that in group B (17.36 ± 10.95) and was statistically significant (P < 0.05). Conclusion For radical resection of low rectal cancer, Simple TaTME resection may be as safe and effective as laparoscopic transabdominal TME, and the long-term prognosis may be better.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Wang-Lin Li
- School of Medicine, South China University of Technology, Guangzhou, China
| |
Collapse
|
5
|
Atkinson MK, Saghafian S. Who should see the patient? on deviations from preferred patient-provider assignments in hospitals. Health Care Manag Sci 2023:10.1007/s10729-022-09628-x. [PMID: 37103616 DOI: 10.1007/s10729-022-09628-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 12/22/2022] [Indexed: 04/28/2023]
Abstract
In various organizations including hospitals, individuals are not forced to follow specific assignments, and thus, deviations from preferred task assignments are common. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from preferred assignments as needed. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children's hospital), and generate insights into whether and when hospital administrators should disallow such flexibility. We do so by identifying 73 top medical diagnoses and using detailed patient-level electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a survey of medical experts and utilized it to identify the preferred provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from preferred provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by 30-day readmissions and adverse events), and cost (measured by total charges). We find that deviating from preferred assignments is beneficial for task types (patients' diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we observe that deviations are either detrimental or yield no tangible benefits, and thus, hospitals should try to eliminate them (e.g., by developing and enforcing assignment guidelines). To understand the causal mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a "no free lunch" theorem: while for some task types, deviations are beneficial for certain performance outcomes, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators, we also consider counterfactual scenarios corresponding to imposing the preferred assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing the preferred assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.
Collapse
Affiliation(s)
- Mariam K Atkinson
- Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, Boston, MA, 02115, USA
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, MA, 02138, USA.
| |
Collapse
|
6
|
Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review. J Robot Surg 2023:10.1007/s11701-023-01546-6. [PMID: 36862348 PMCID: PMC9979125 DOI: 10.1007/s11701-023-01546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review. METHODS We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery. RESULTS Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage. CONCLUSION Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.
Collapse
|
7
|
Shao SL, Li YK, Qin JC, Liu L. Comprehensive abdominal composition evaluation of rectal cancer patients with anastomotic leakage compared with body mass index-matched controls. World J Gastrointest Surg 2022; 14:1250-1259. [PMID: 36504512 PMCID: PMC9727572 DOI: 10.4240/wjgs.v14.i11.1250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/27/2022] [Accepted: 11/04/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a fatal complication in patients with rectal cancer after undergoing anterior resection. However, the role of abdominal composition in the development of AL has not been studied.
AIM To investigate the relationship between abdominal composition and AL in rectal cancer patients after undergoing anterior resection.
METHODS A retrospective case-matched cohort study was conducted. Complete data for 78 patients with AL were acquired and this cohort was defined as the AL group. The controls were matched for the same sex and body mass index (± 1 kg/m2). Parameters related to abdominal composition including visceral fat area (VFA), subcutaneous fat area (SFA), subcutaneous fat thickness (SFT), skeletal muscle area (SMA), skeletal muscle index (SMI), abdominal circumference (AC), anterior to posterior diameter of abdominal cavity (APD), and transverse diameter of abdominal cavity (TD) were evaluated based on computed tomography (CT) images using the following Hounsfield Unit (HU) thresholds: SFA: -190 to -30, SMA: -29 to 150, and VFA: -150 to -20. The significance of abdominal composition-related parameters was quantified using feature importance analysis; an artificial intelligence method was used to evaluate the contribution of each included variable.
RESULTS Two thousand two hundred and thirty-eight rectal cancer patients who underwent anterior resection from 2010 to 2020 in a large academic hospital were investigated. Finally, 156 cases were enrolled in the study. Patients in the AL group showed longer operative time (225.03 ± 55.29 vs 207.17 ± 40.80, P = 0.023), lower levels of preoperative hemoglobin (123.32 ± 21.17 vs 132.60 ±1 6.31, P = 0.003) and albumin (38.34 ± 4.01 vs 40.52 ± 3.97, P = 0.001), larger tumor size (4.07 ± 1.36 vs 2.76 ± 1.28, P < 0.001), and later cancer stage (P < 0.001) compared to the controls. Patients who developed AL exhibited a larger VFA (125.68 ± 73.59 vs 97.03 ± 57.66, P = 0.008) and a smaller APD (77.30 ± 23.23 vs 92.09 ± 26.40, P < 0.001) and TD (22.90 ± 2.23 vs 24.21 ± 2.90, P = 0.002) compared to their matched controls. Feature importance analysis revealed that TD, APD, and VFA were the three most important abdominal composition-related features.
CONCLUSION AL patients have a higher visceral fat content and a narrower abdominal structure compared to matched controls.
Collapse
Affiliation(s)
- Sheng-Li Shao
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Yang-Kun Li
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ji-Chao Qin
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Lu Liu
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| |
Collapse
|
8
|
Gutierrez L, Bonne A, Trilling B, Foote A, Laverrière MH, Roth G, Fournier J, Girard E, Faucheron JL. Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer. Tech Coloproctol 2022; 27:407-418. [PMID: 36326939 DOI: 10.1007/s10151-022-02725-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients. METHODS This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients. RESULTS Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively). CONCLUSIONS Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.
Collapse
Affiliation(s)
- L Gutierrez
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - A Bonne
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - B Trilling
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, 38000, Grenoble, France
- University Grenoble Alpes, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - A Foote
- Research Division, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - M-H Laverrière
- Department of Pathology, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - G Roth
- Department of Hepato-Gastroenterology, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - J Fournier
- Department of Public Health, Grenoble Alpes University Hospital, 38000, Grenoble, France
| | - E Girard
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, 38000, Grenoble, France
- University Grenoble Alpes, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - J-L Faucheron
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, 38000, Grenoble, France.
- University Grenoble Alpes, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France.
| |
Collapse
|
9
|
Fletcher JA, Drami I, Sayers A, El-Sayed C, Sarmah P, Vaughan-Shaw P, Jenkins JT. The Dukes' Club fundamentals of colorectal surgery video series: A stepwise approach to laparoscopic total mesorectal excision-A video vignette. Colorectal Dis 2022; 24:1445-1446. [PMID: 35666165 DOI: 10.1111/codi.16215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/31/2022] [Accepted: 05/27/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jordan A Fletcher
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.,St Mark's Hospital and Academic Institute, Harrow, UK
| | - Ioanna Drami
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.,St Mark's Hospital and Academic Institute, Harrow, UK
| | | | - Charlotte El-Sayed
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - Panchali Sarmah
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - Peter Vaughan-Shaw
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - John T Jenkins
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.,St Mark's Hospital and Academic Institute, Harrow, UK.,Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| |
Collapse
|
10
|
The Multidisciplinary Approach of Rectal Cancer: The Experience of "COMRE Group" Model. Diagnostics (Basel) 2022; 12:diagnostics12071571. [PMID: 35885477 PMCID: PMC9319737 DOI: 10.3390/diagnostics12071571] [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: 04/14/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Total mesorectal excision (TME) is the gold standard to treat locally advanced rectal cancer. This monocentric retrospective study evaluates the results of laparotomic, laparoscopic and robotic surgery in “COMRE GROUP” (REctalCOMmittee). Methods: 327 selected stage I-II-III patients (pts) underwent TME between November 2005 and April 2020 for low or middle rectal cancer; 91 pts underwent open, 200 laparoscopic and 36 robotic TME. Of these, we analyzed the anthropomorphic, intraoperative, anatomopathological parameters and outcome during the follow up. Results: The length of hospital stay was significantly different between robotic TME and the other two groups (8.47 ± 3.54 days robotic vs. 11.93 ± 5.71 laparotomic, p < 0.001; 8.47 ± 3.54 robotic vs. 11.10 ± 7.99 laparoscopic, p < 0.05). The mean number of harvested nodes was higher in the laparotomic group compared to the other two groups (19 ± 9 laparotomic vs. 15 ± 8 laparoscopic, p < 0.001; 19 ± 9 laparotomic vs. 15 ± 7 robotic, p < 0.05). Median follow-up was 52 months (range: 1−169). Overall survival was significantly shorter in the open TME group compared with the laparoscopic one (Chi2 = 13.36, p < 0.001). Conclusions: In the experience of the “COMRE” group, laparoscopic TME for rectal cancer is a better choice than laparotomy in a multidisciplinary context. Robotic TME has a significant difference in terms of hospital stay compared to the other two groups.
Collapse
|
11
|
Pelvines intraoperatives Neuromonitoring. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00618-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
12
|
The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-1265. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
Collapse
|
13
|
Yule S, Gupta A, Blair PG, Sachdeva AK, Smink DS. Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context. JOURNAL OF SURGICAL EDUCATION 2021; 78:955-966. [PMID: 33041250 DOI: 10.1016/j.jsurg.2020.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/31/2020] [Accepted: 09/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context. STUDY DESIGN A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion. RESULTS A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected. CONCLUSIONS A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.
Collapse
Affiliation(s)
- Steven Yule
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham & Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Center for Surgery & Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland.
| | - Avni Gupta
- Center for Surgery & Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Center for Surgery & Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
14
|
Abstract
OBJECTIVE To investigate the frequency, nature, and severity of intraoperative adverse near miss events within advanced laparoscopic surgery and report any associated clinical impact. BACKGROUND Despite implementation of surgical safety initiatives, the intraoperative period is poorly documented with evidence of underreporting. Near miss analyses are undertaken in high-risk industries but not in surgical practice. METHODS Case video and data from 2 laparoscopic total mesorectal excision randomized controlled trials were analyzed (ALaCaRT ACTRN12609000663257, 2D3D ISRCTN59485808). Intraoperative adverse events were identified and categorized using the observational clinical human reliability analysis technique. The EAES classification was applied by 2 blinded assessors. EAES grade 1 events (nonconsequential error, no damage, or need for correction) were considered near misses. Associated clinical impact was assessed with early morbidity and histopathology outcomes. RESULTS One hundred seventy-five cases contained 1113 error events. Six hundred ninety-eight (62.7%) were near misses (median 3, IQR 2-5, range 0-15) with excellent inter-rater and test-retest reliability (κ=0.86, 95% CI 0.83-0.89, P < 0.001 and κ=0.88, 95% CI 0.85-0.9, P < 0.001 respectively). Significantly more near misses were seen in patients who developed early complications (4 (3-6) vs. 3 (2-4), P < 0.001). Higher numbers of near misses were seen in patients with more numerous (P = 0.002) and more serious early complications (P = 0.003). Cases containing major intraoperative adverse events contained significantly more near misses (5 (3-7) vs. 3 (2-5), P < 0.001) with a major event observed for every 19.4 near misses. CONCLUSION Intraoperative adverse events and near misses can be reliably and objectively captured in advanced laparoscopic surgery. Near misses are commonplace and closely associated with morbidity outcomes.
Collapse
|
15
|
A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival. Langenbecks Arch Surg 2021; 406:813-819. [PMID: 33638682 DOI: 10.1007/s00423-021-02122-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: 06/24/2020] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach. METHODS This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures. RESULTS A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively. CONCLUSION Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.
Collapse
|
16
|
Does the Endoscopic Surgical Skill Qualification System improve patients' outcome following laparoscopic surgery for colon cancer? A multicentre, retrospective analysis with propensity score matching. World J Surg Oncol 2021; 19:53. [PMID: 33608034 PMCID: PMC7893747 DOI: 10.1186/s12957-021-02155-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/31/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study aimed to investigate the short-term and oncological impact of the Endoscopic Surgical Skill Qualification System (ESSQS) by the Japan Society for Endoscopic Surgery on the operator performing laparoscopic surgery for colon cancer. METHODS This retrospective cohort study was based on medical records from a multicentre database. A total of 417 patients diagnosed with stage II/III colon and rectosigmoid cancer treated with curative resection were divided into two groups according to whether they were operated on by qualified surgeons (Q group, n=352) or not (NQ group, n=65). Through strict propensity score matching, 98 cases (49 in each group) were assessed. RESULTS Operative time was significantly longer in the NQ group than in the Q group (199 vs. 168 min, p=0.029). The amount of blood loss, post-operative complications, and duration of hospitalisation were similar between both groups. No mortality was observed. One conversion case was seen in the NQ group. The 3-year recurrence-free survival rate was 86.6% in the NQ group and 88.2% in the Q group, which was not statistically significant (log-rank p=0.966). CONCLUSION Direct operation by ESSQS-qualified surgeons contributed to a shortened operation time. Under an organised educational environment, almost equivalent safety and oncological outcomes are expected regardless of the surgeon's qualifications.
Collapse
|
17
|
Curtis NJ, Foster JD, Miskovic D, Brown CSB, Hewett PJ, Abbott S, Hanna GB, Stevenson ARL, Francis NK. Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery. JAMA Surg 2021; 155:590-598. [PMID: 32374371 DOI: 10.1001/jamasurg.2020.1004] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear. Objective To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. Design, Setting, and Participants This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases. Interventions Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons. Main Outcomes and Measures Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. Results The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). Conclusions and Relevance Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.
Collapse
Affiliation(s)
- Nathan J Curtis
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | - Jake D Foster
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | | | - Chris S B Brown
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Peter J Hewett
- Department of Surgery, University of Adelaide, Adelaide, Australia
| | - Sarah Abbott
- Canterbury District Health Board, Christchurch, New Zealand
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, England
| | - Andrew R L Stevenson
- Faculty of Medical and Biomedical Sciences, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England.,University College London, London, England
| |
Collapse
|
18
|
Li Y, Liu D, Zhao L, Güngör C, Song X, Wang D, Liu W, Tan F. Accurate nomograms with excellent clinical value for locally advanced rectal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:296. [PMID: 33708923 PMCID: PMC7944304 DOI: 10.21037/atm-20-4144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Rectal cancer accounts for approximately 30–50% of colorectal cancer. Despite its widespread use and convenience, the American Joint Committee on Cancer (AJCC) staging system for predicting survival is prone to inaccuracy, even including a survival paradox for locally advanced rectal cancer (LARC). An accurate risk stratification of LARC is essential for proper treatment selection and prognostic evaluation. Therefore, we aimed to create prognostic nomograms for LARC capable of assessing overall survival (OS) and cancer-specific survival (CSS) precisely and intuitively. Methods The Surveillance, Epidemiology, and End Results (SEER) database was accessed. All of the significant variables in the multivariate analysis were integrated to build the nomograms. Results Data for a total of 23,055 patients with LARC were collected from the SEER database in this study. Based on the multivariate Cox regression analysis, both OS and CSS were significantly associated with 13 variables: age, marital status, race, pathological grade, histological type, T stage, N stage, surgery, radiotherapy, chemotherapy, regional nodes examined (RNE), tumor size, and carcinoembryonic antigen (CEA). These were included in the construction of nomograms for OS and CSS. Time-dependent receiver operating characteristic (ROC) curves, decision curve analysis (DCA), concordance index, and calibration curves demonstrated the discriminative superiority of the nomograms. Conclusions The nomograms, which effectively solve the issue of the survival paradox in the AJCC staging system regarding LARC, may act as excellent tools for integrating clinical characteristics and to guiding therapeutic choices for LARC patients.
Collapse
Affiliation(s)
- Yuqiang Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Da Liu
- Shanxi Medical University, Taiyuan, China
| | - Lilan Zhao
- Department of Thoracic surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Cenap Güngör
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Xiangping Song
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Dan Wang
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wenxue Liu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China.,Department of Rheumatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fengbo Tan
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
19
|
Yiasemidou M, Mushtaq F, Basheer M, Galli R, Panagiotou D, Stock S, Preston N, Mon-Williams M, Jayne DG, Miskovic D. Patient-specific mental rehearsal with three-dimensional models before low anterior resection: randomized clinical trial. BJS Open 2020. [PMCID: PMC7944490 DOI: 10.1093/bjsopen/zraa004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background It was hypothesized that preparing for a surgical procedure, taking into account individual patient characteristics, may facilitate the procedure and improve surgical quality. The aim of this study was to compare different case-specific, preoperative mental rehearsal methods before minimally invasive rectal cancer surgery. Methods In this RCT, patients were allocated in a 1 : 1 : 1 : 1 ratio to four groups: systematic mental rehearsal (SMR) using MRI scans; SMR and three-dimensional (3D) virtual models; SMR and synthetic 3D printed models; and routine practice (control group). Surgeons operating on all but the control group underwent mental rehearsal with the visual aids, including axial MRI scans of the pelvis, interactive 3D virtual models reconstructed from axial MRIs, and synthetic models, manufactured by 3D printing. Operations were video-recorded and assessed by two experts blinded to allocation using two validated scores, the Competency Assessment Tool (CAT) and Objective Clinical Human Reliability Analysis (OCHRA). The primary outcome of the study was surgical performance, measured by the CAT. Results Forty-nine patients were randomized and allocated to the four groups. There were 12 participants in each of the control, MRI and SMR, and virtual and SMR groups, whereas the SMR using physical models and simulation group included 13. No difference was observed between groups in median CAT scores (control 30.50, MRI 34.25, virtual 31.75, physical 34.00; P = 0.748, partial η2 <0.001, where pη2 is indicative of effect size) or OCHRA scores (anterior, posterior, right and left lateral planes, transection P>0.200, pη2 =0.052–0.088). Time spent not performing dissection was significantly shorter for the SMR with MRI group than for the control (57.5 versus 42 respectively; P < 0.001, pη2 =0.212). Conclusion Mental rehearsal did not affect CAT and OCHRA scores of consultant surgeons. Reference number: ISRCTN 75603704 (https://www.isrctn.com).
Collapse
Affiliation(s)
- M Yiasemidou
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, St James’s University Hospital, Leeds, UK
- Academic Surgery, University of Hull, Hull, UK
| | - F Mushtaq
- School of Psychology, University of Leeds, Leeds, UK
| | - M Basheer
- Department of Colorectal Surgery, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - R Galli
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | - D Panagiotou
- General Surgery, York Teaching Hospital, York, UK
| | - S Stock
- General and Trauma Surgery, World Mate Emergency Hospital, Battambang, Cambodia
| | - N Preston
- School of Psychology, University of Leeds, Leeds, UK
| | | | - D G Jayne
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, St James’s University Hospital, Leeds, UK
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | - D Miskovic
- Department of Colorectal Surgery, St Mark’s Hospital, Harrow, London, UK
| |
Collapse
|
20
|
Fong Y, Buell JF, Collins J, Martinie J, Bruns C, Tsung A, Clavien PA, Nachmany I, Edwin B, Pratschke J, Solomonov E, Koenigsrainer A, Giulianotti PC. Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum. Surg Endosc 2020; 34:4233-4244. [PMID: 32767146 DOI: 10.1007/s00464-020-07836-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons. METHODS In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds. RESULTS Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training. CONCLUSIONS Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.
Collapse
Affiliation(s)
- Yuman Fong
- Department of Surgery, City of Hope Medical Center, 1500 East Duarte Road, Duarte, CA, 91011, USA.
| | - Joseph F Buell
- Department of Surgery, Mission Healthcare, HCA Healthcare, North Carolina Division, MAHEC University of North Carolina, Asheville, NC, USA
| | - Justin Collins
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - John Martinie
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Allan Tsung
- Department of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Ido Nachmany
- Department of "Surgery B". Tel Aviv Sourasky Medical Center, Tel Aviv & The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Evgeny Solomonov
- Department of General and Hepato-Pancreatico-Biliary and Transplant Surgery, Ziv Medical Centre, Zefat (Safed), Israel
| | - Alfred Koenigsrainer
- Department of General, Visceral, Cancer and Surgery, University of Tuebingen, Tuebingen, Germany
| | | |
Collapse
|
21
|
Huang S, Chen M, Deng Y, Wang X, Lu X, Jiang W, Huang Y, Chi P. Mesorectal fat area and mesorectal area affect the surgical difficulty of robotic-assisted mesorectal excision and intersphincteric resection respectively in different ways. Colorectal Dis 2020; 22:1130-1138. [PMID: 32040248 DOI: 10.1111/codi.15012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Abstract
AIM Many studies have demonstrated predictors of the difficulty of laparoscopic anterior resection for rectal cancer. Few studies focus on the influence of pelvic dimensions on robotic-assisted mesorectal excision (ME) and intersphincteric resection (ISR). This study aimed to evaluate the influences of the mesorectal fat area (MFA) and mesorectal area on the difficulty of robotic sphincter-saving surgery. METHODS We included 156 patients with middle and low rectal cancer who underwent robotic sphincter-saving surgery. Clinical and anatomical factors, including the pelvic dimensions, were collected. Linear regression was performed for variables associated with surgical duration. We also performed subgroup analyses for robotic-assisted ME and ISR. Logistic regression was used to find variables associated with transanal dissection. RESULTS For patients with middle or low rectal cancer, the sacral length and tumour distance from the anal verge were independently associated with surgical duration. The pT stage, sacral length and the MFA were independent predictors for the surgical duration of robotic-assisted ME. By contrast, a small mesorectal area was independently related to a longer duration of robotic-assisted ISR. The pelvic outlet length was independently associated with the use of transanal dissection for ISR. CONCLUSION It is suggested that a large MFA could affect the difficulty of ME in robotic-assisted ME, while a small mesorectal area could increase the surgical difficulty of robotic-assisted ISR for low rectal cancer. Besides, the pelvic outlet length was associated with the use of transanal dissection. Further studies are needed to validate the results and draw more scientific conclusions.
Collapse
Affiliation(s)
- S Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - M Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Lu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - W Jiang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - P Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| |
Collapse
|
22
|
Results of laparoscopic resection in high-risk rectal cancer patients. Langenbecks Arch Surg 2020; 405:479-490. [PMID: 32472173 DOI: 10.1007/s00423-020-01892-1] [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: 03/19/2020] [Accepted: 05/03/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Obesity, neoadjuvant-radiotherapy, tumour proximity to the anal verge and previous abdominal surgery are factors that might increase the intra-operative difficulty of laparoscopic rectal cancer surgery. However, whether patients with these 'high-risk' characteristics are subject to worse short- or long-term outcomes is debated. The aim of this study is to examine the short- and long-term clinical and oncological outcomes of patients receiving laparoscopic rectal surgery with any of these high-risk characteristics and compare them with patients that do not possess any of these high-risk features. METHODS For the purpose of this study data from consecutive patients receiving laparoscopic rectal cancer resections between 2006 and 2016 from two centres were analysed. High-risk patients were defined as patients with either one of the following characteristics: BMI ≥ 30, neoadjuvant chemoradiotherapy, tumour < 8 cm from the anal verge and previous abdominal surgery. RESULTS A total of 313 patients were identified (227 high risk, 86 low risk). Short-term outcomes were similar between the two groups with the exception of blood loss and length of stay, which were higher in the high-risk group (10 vs 2.5 ml, p = 0.045; 7 vs 5 days, p = 0.001). There were no statistically significant differences in 5-year overall survival (79.7% vs 79.8%, p = 0.757), disease-free survival (76.8% vs 69.3%, p = 0.175), distant disease-free interval (84.8% vs 79.7%, p = 0.231) and local recurrence-free interval (100%, 97.4%, p = 0.162) between the two groups. CONCLUSION Similar short- and long-term outcomes can be achieved in high-risk and low-risk patients receiving laparoscopic rectal surgery. The presented data support the suitability of laparoscopic surgery for this group of patients.
Collapse
|
23
|
Ku DH, Kim HS, Shin JY. Short-term and Medium-term Outcomes of Low Midline and Low Transverse Incisions in Laparoscopic Rectal Cancer Surgery. Ann Coloproctol 2020; 36:304-310. [PMID: 32054255 PMCID: PMC7714381 DOI: 10.3393/ac.2019.10.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
Purpose Limited data exist on the use of low midline and transverse incisions for specimen extraction or stoma sites in laparoscopic rectal cancer surgery (LRCS). We compared the short-term and medium-term outcomes of these incisions and assessed whether wound complications in specimen extraction sites (SES) are increased by specimen extraction through the stoma site (SESS) in LRCS. Methods From March 2010 to December 2017, 189 patients who underwent LRCS and specimen extraction through low abdominal incisions were divided into 2 groups: midline (n = 102) and transverse (n = 87), and perioperative outcomes were compared. Results The midline group showed a higher frequency of temporary stoma formation (P = 0.001) and splenic flexure mobilization (P < 0.001) than the transverse group. The overall incisional hernia and wound infection rates in the SES were 21.6% and 25.5%, respectively, in the midline group and 26.4% and 17.2%, respectively, in the transverse group (P = 0.494 and P = 0.232, respectively). In patients who underwent SESS, the incisional hernia and wound infection rates of SES after stoma closure were 39.1% and 43.5%, respectively, in the midline group, and 35.5% and 22.6%, respectively, in the transverse group (P = 0.840 and P = 0.035, respectively). Conclusion In terms of incisional hernia and wound infection at the SES, a low midline incision may be used as a low transverse incision in patients without temporary stoma in LRCS. However, considering the high wound complication rates after stoma closure in patients with SESS in this study, SESS should be performed with caution in LRCS.
Collapse
Affiliation(s)
- Do Hoe Ku
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyeon Seung Kim
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Yong Shin
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
24
|
Kanters AE, Cleary RK, Obi SH, Asgeirsson T, Evilsizer SK, Fasbinder LG, Campbell DA, Hendren SK. Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study. Dis Colon Rectum 2020; 63:53-59. [PMID: 31633602 PMCID: PMC6895431 DOI: 10.1097/dcr.0000000000001526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. OBJECTIVE We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. DESIGN This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. SETTINGS Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. PATIENTS Patients who underwent rectal cancer resection were included. MAIN OUTCOME MEASURE The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. RESULTS Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). LIMITATIONS This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. CONCLUSIONS The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.
Collapse
Affiliation(s)
- Arielle E. Kanters
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI,Correspondence: Arielle Kanters, MD, Center for Healthcare Outcomes and Policy, 2800 Plymouth Road Building 16, Office 016-168C, Ann Arbor, MI 48105. . Twitter: arikanters, Presentation of work, Telephone: 734-998-7470, Fax: 734-998-7473
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI
| | - Shawn H. Obi
- Department of Surgery, Henry Ford Allegiance, Jackson, MI
| | | | | | | | - Darrell A. Campbell
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Samantha K. Hendren
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
| |
Collapse
|
25
|
Abstract
BACKGROUND Laparoscopic total mesorectal excision is a challenging procedure requiring high-quality surgery for optimal outcomes. Patient, tumor, and pelvic factors are believed to determine difficulty, but previous studies were limited to postoperative data. OBJECTIVE This study aimed to report factors predicting laparoscopic total mesorectal excision performance by using objective intraoperative assessment. DESIGN Data from a multicenter laparoscopic total mesorectal excision randomized trial (ISRCTN59485808) were reviewed. SETTING This study was conducted at 4 centers in the United Kingdom. PATIENTS AND INTERVENTION Seventy-one patients underwent elective laparoscopic total mesorectal excision for rectal adenocarcinoma with curative intent: 53% were men, mean age was 69 years, body mass index was 27.7, tumor height was 8.5 cm, 24% underwent neoadjuvant therapy, and 25% had previous surgery. MAIN OUTCOME MEASURES Surgical performance was assessed through the identification of intraoperative adverse events by using observational clinical human reliability analysis. Univariate analysis and multivariate binomial regression were performed to establish factors predicting the number of intraoperative errors, surgeon-reported case difficulty, and short-term clinical and histopathological outcomes. RESULTS A total of 1331 intraoperative errors were identified from 365 hours of surgery (median, 18 per case; interquartile range, 16-22; and range, 9-49). No patient, tumor, or bony pelvimetry measurement correlated with total or pelvic error count, surgeon-reported case difficulty, cognitive load, operative data, specimen quality, number or severity of 30-day morbidity events and length of stay (all r not exceeding ±0.26, p > 0.05). Mesorectal area was associated with major intraoperative adverse events (OR, 1.09; 95%CI, 1.01-1.16; p = 0.015) and postoperative morbidity (OR, 1.1; 95% CI, 1.01-1.2; p = 0.033). Obese men were subjectively reported as harder cases (24 vs 36 mm, p = 0.042), but no detrimental effects on performance or outcomes were seen. LIMITATIONS Our sample size is modest, risking type II errors and overfitting of the statistical models. CONCLUSION Patient, tumor, and bony pelvic anatomical characteristics are not seen to influence laparoscopic total mesorectal excision operative difficulty. Mesorectal area is identified as a risk factor for intraoperative and postoperative morbidity. See Video Abstract at http://links.lww.com/DCR/B35. FACTORES QUE PREDICEN LA DIFICULTAD OPERATIVA DE LA ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA: La escisión mesorrectal total laparoscópica es un procedimiento desafiante. Para obtener resultados óptimos, se requiere cirugía de alta calidad. Se cree que, factores como el paciente, el tumor y la pelvis, determinan la dificultad, pero estudios previos solamente se han limitado a datos postoperatorios.Informar de los factores que predicen el resultado de la escisión mesorrectal total laparoscópica, mediante una evaluación intraoperatoria objetiva.Datos de un ensayo multicéntrico y randomizado de escisión mesorrectal total laparoscópica (ISRCTN59485808).Cuatro centros del Reino Unido.Un total de 71 pacientes fueron sometidos a escisión mesorrectal total laparoscópica electiva, para adenocarcinoma rectal con intención curativa. 53% hombres, edad media, índice de masa corporal y altura del tumor 69, 27.7 y 8.5 cm respectivamente, 24% terapia neoadyuvante y 25% cirugía previa.Rendimiento quirúrgico evaluado mediante la identificación de eventos intraoperatorios adversos, mediante el análisis clínico observacional de confiabilidad humana. Se realizaron análisis univariado y la regresión binomial multivariada para establecer factores que predicen el número de errores intraoperatorios, reportes del cirujano sobre la dificultad del caso y los resultados clínicos e histopatológicos a corto plazo.Se identificaron un total de 1,331 errores intraoperatorios en 365 horas de cirugía (media de 18 por caso, IQR 16-22, rango 9-49). Ningún paciente, tumor o medición de pelvimetría pélvica, se correlacionó con la cuenta de errores pélvicos o totales, reporte del cirujano sobre dificultad del caso, carga cognitiva, datos operativos, calidad de la muestra, número o gravedad de eventos de morbilidad de 30 días y duración de la estadía (todos r <± 0.26, p > 0.05). El área mesorrectal se asoció con eventos adversos intraoperatorios importantes (OR, 1.09; IC 95%, 1.01-1.16; p = 0.015) y morbilidad postoperatoria (OR, 1.1; IC 95%, 1.01-1.2; p = 0.033). Como información subjetiva, hombres obesos fueron casos más difíciles (24 mm frente a 36 mm, p = 0.042) pero no se observaron efectos perjudiciales sobre el rendimiento o los resultados.Nuestro tamaño de muestra es un modesto riesgo de errores de tipo II y el sobreajuste de los modelos estadísticos.No se observa que las características anatómicas del paciente, tumor y pelvis ósea influyan en la dificultad operatoria de la escisión mesorrectal laparoscópica total. El área mesorrectal se identifica como un factor de riesgo para la morbilidad intraoperatoria y postoperatoria. Vea el resumen del video en http://links.lww.com/DCR/B35.
Collapse
|
26
|
Standardised approach to laparoscopic total mesorectal excision for rectal cancer: a prospective multi-centre analysis. Langenbecks Arch Surg 2019; 404:547-555. [PMID: 31377857 DOI: 10.1007/s00423-019-01806-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high-quality surgery are equivalent to those achieved by open technique. We present short- and long-term post-operative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic TME for rectal cancer. We describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. METHODS Prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon at the minimally invasive colorectal unit in Portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons at three further international centres. Endpoints were overall and disease-free survival at 5 years, and early post-operative clinical and pathological outcomes. RESULTS Two hundred sixty-three consecutive patients underwent laparoscopic TME surgery by the principal surgeon. At 5 years, overall survival was 82.9% (Dukes' A = 94.4%; B = 81.6%; C = 73.7%); disease-free survival was 84.0% (Dukes' A = 93.3%; B = 86.8%; C = 72.6%). Post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, major morbidity and 30-day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. CONCLUSION Laparoscopic TME produces excellent long-term survival outcomes for patients with rectal cancer. A standardised approach has the potential to improve outcomes by setting benchmarks for surgical quality, and providing a step-by-step method for surgical training.
Collapse
|
27
|
Li Y, Zhao L, Güngör C, Tan F, Zhou Z, Li C, Song X, Wang D, Pei Q, Liu W. The main contributor to the upswing of survival in locally advanced colorectal cancer: an analysis of the SEER database. Therap Adv Gastroenterol 2019; 12:1756284819862154. [PMID: 31360223 PMCID: PMC6640067 DOI: 10.1177/1756284819862154] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/11/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is no conclusion about the most important contributor to the upswing of locally advanced colorectal cancer (LACRC) survival. METHODS Data from the Surveillance, Epidemiology, and End Results (SEER) database was extracted to identify colorectal adenocarcinoma cancer patients at stage II and III diagnosed in the two periods 1989-1990 and 2009-2010. The statistical methods included Pearson's chi-squared test, log-rank test, Cox regression model and propensity score matching. RESULTS The Cox regression model showed that hazard ratio (HR) of non-surgery dropped from 11.529 to 3.469 in right colon cancer (RCC), 5.214 to 2.652 in left colon cancer (LCC) and 3.275 to 3.269 in rectal cancer (RC) from 1989-1990 to 2009-2010. The 95% confidence intervals (CIs) for surgical resection in 2009-2010 were narrower than those in 1989-1990. HR became greater in LACRC without chemotherapy (from 1.337 to 1.779 in RCC, 1.269 to 2.017 in LCC, 1.317 to 1.811 in RC). There was no overlapping about the 95% CI of chemotherapy between the two groups. The progress of surgery was not linked to the improvement of overall survival (OS) of RCC (p = 0.303) and RC (p = 0.660). Chemotherapy had a significant association with OS of all colorectal cancer (CRC) patients (p = 0.017 in RCC; p = 0.006 in LCC; p = 0.001 in RC). CONCLUSIONS Advancements in chemotherapy regimen were the main contributor to the upswing of CRC survival. The improvements in surgery had a limited effect on improvements in CRC survival.
Collapse
Affiliation(s)
- Yuqiang Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lilan Zhao
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cenap Güngör
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fengbo Tan
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongyi Zhou
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Chenglong Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangping Song
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Dan Wang
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | | | - Wenxue Liu
- Department of Cardiology and National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, P.R. China
| |
Collapse
|
28
|
Shah MF, Nasir IUI, Parvaiz A. Robotic Surgery for Colorectal Cancer. Visc Med 2019; 35:247-250. [PMID: 31602387 DOI: 10.1159/000500785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 01/21/2023] Open
Abstract
Master-slave manipulators (otherwise known as telemanipulators) were introduced into minimally invasive surgery in the 1990s to overcome the limitations of laparoscopic surgery. This led to the development of the first robotic surgical systems which, over the last 10 years, have rapidly gained acceptance among colorectal surgeons. Advantages of robotic surgical systems such as superior instrumentation and field of vision enable precise dissection in confined spaces such as the pelvis, which make it a particularly attractive tool for rectal surgery. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior peri- and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skill. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.
Collapse
Affiliation(s)
- Muhammad Fahd Shah
- Advanced Laparoscopy and Robotic Surgery, Poole Hospital NHS Trust, Poole, United Kingdom
| | - Irfan Ul Islam Nasir
- Advanced Laparoscopy and Robotic Surgery, Champalimaud Foundation, Lisbon, Portugal
| | - Amjad Parvaiz
- Surgery and Colorectal Surgery, Poole Hospital NHS Trust, Poole, United Kingdom.,Minimal Access and Robotic Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
29
|
Miskovic D, Ahmed J, Bissett-Amess R, Gómez Ruiz M, Luca F, Jayne D, Figueiredo N, Heald RJ, Spinoglio G, Parvaiz A. European consensus on the standardization of robotic total mesorectal excision for rectal cancer. Colorectal Dis 2019; 21:270-276. [PMID: 30489676 DOI: 10.1111/codi.14502] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
Abstract
AIM Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency-based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons. METHOD A Delphi questionnaire with a 72-item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval. RESULTS The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75-1). CONCLUSION This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.
Collapse
Affiliation(s)
- D Miskovic
- Department of Colorectal Surgery, St Mark's Hospital Harrow, London, UK
| | - J Ahmed
- Champalimaud Clinical Centre - Champalimaud Foundation, Lisbon, Portugal
| | - R Bissett-Amess
- Champalimaud Clinical Centre - Champalimaud Foundation, Lisbon, Portugal
| | - M Gómez Ruiz
- Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - F Luca
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - D Jayne
- St James's University Hospital, University of Leeds, Leeds, UK
| | - N Figueiredo
- Champalimaud Clinical Centre - Champalimaud Foundation, Lisbon, Portugal
| | - R J Heald
- Champalimaud Clinical Centre - Champalimaud Foundation, Lisbon, Portugal
| | - G Spinoglio
- Surgical Department, National Hospital, Alessandria, Italy
| | - A Parvaiz
- Director of European Academy of Robotic Colorectal Surgery (EARCS), Champalimaud Foundation, Lisbon, Portugal.,Head of Laparoscopic & Robotic Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal.,Laparoscopic and Robotic Colorectal Surgery, Poole General Hospital, Poole, UK
| | | |
Collapse
|
30
|
2D versus 3D laparoscopic total mesorectal excision: a developmental multicentre randomised controlled trial. Surg Endosc 2019; 33:3370-3383. [PMID: 30656453 PMCID: PMC6722156 DOI: 10.1007/s00464-018-06630-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
AIMS The role of laparoscopy in rectal cancer has been questioned. 3D laparoscopic systems are suggested to aid optimal surgical performance but have not been evaluated in advanced procedures. We hypothesised that stereoscopic imaging could improve the performance of laparoscopic total mesorectal excision (TME). METHODS A multicentre developmental randomised controlled trial comparing 2D and 3D laparoscopic TME was performed (ISRCTN59485808). Trial surgeons were colorectal consultants that had completed their TME proficiency curve and underwent stereoscopic visual testing. Patients requiring elective laparoscopic TME with curative intent were centrally randomised (1:1) to 2D or 3D using Karl Storz IMAGE1 S D3-Link™ and 10-mm TIPCAM®1S 3D passive polarising laparoscopic systems. Outcomes were enacted adverse events as assessed by the observational clinical human reliability analysis technique, intraoperative data, 30-day patient outcomes, histopathological specimen assessment and surgeon cognitive load. RESULTS 88 patients were included. There were no differences in patient or tumour demographics, surgeon stereopsis, case difficulty, cognitive load, operative time, blood loss or conversion between the trial arms. 1377 intraoperative adverse events were identified (median 18 per case, IQR 14-21, range 2-49) with no differences seen between the 2D and 3D arms (18 (95% CI 17-21) vs. 17 (95% CI 16-19), p = 0.437). 3D laparoscopy had non-significantly higher mesorectal fascial plane resections (94 vs. 77%, p = 0.059; OR 0.23 (95% CI 0.05-1.16)) but equal lymph node yield and circumferential margin distance and involvement. 30-day morbidity, anastomotic leak, re-operation, length of stay and readmission rates were equal between the 2D and 3D arms. CONCLUSION Feasibility of performing multicentre 3D laparoscopic multicentre trials of specialist performed complex procedures is shown. 3D imaging did not alter the number of intraoperative adverse events; however, a potential improvement in mesorectal specimen quality was observed and should form the focus of future 3D laparoscopic TME trials.
Collapse
|
31
|
Cleary RK, Morris AM, Chang GJ, Halverson AL. Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach? Ann Surg Oncol 2018; 25:3587-3595. [DOI: 10.1245/s10434-018-6740-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/15/2022]
|
32
|
Vieira P, Tayyab M, Domingos H, Cunha J, Heald R, Figueiredo N, Parvaiz A. Standardized approach to robotic right colectomy - a video vignette. Colorectal Dis 2018; 20:827-828. [PMID: 29772121 DOI: 10.1111/codi.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Affiliation(s)
- P Vieira
- Department of Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - M Tayyab
- Department of Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - H Domingos
- Department of Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - J Cunha
- Department of Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - R Heald
- Pelican Cancer Foundation, Basingstoke, UK
| | - N Figueiredo
- Department of Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - A Parvaiz
- Department of Colorectal Surgery, Poole Hospital, Poole, UK
| |
Collapse
|
33
|
Panteleimonitis S, Pickering O, Abbas H, Harper M, Kandala N, Figueiredo N, Qureshi T, Parvaiz A. Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy: a comparative propensity scored match study. Int J Colorectal Dis 2018; 33:1079-1086. [PMID: 29577170 PMCID: PMC6060802 DOI: 10.1007/s00384-018-3030-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Laparoscopic rectal surgery in obese patients is technically challenging. The technological advantages of robotic instruments can help overcome some of those challenges, but whether this translates to superior short-term outcomes is largely unknown. The aim of this study is to compare the short-term surgical outcomes of obese (BMI ≥ 30) robotic and laparoscopic rectal cancer surgery patients. METHODS All consecutive obese patients receiving laparoscopic and robotic rectal cancer resection surgery from three centres, two from the UK and one from Portugal, between 2006 and 2017 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for ASA grade, neoadjuvant radiotherapy and pathological T stage. Their short-term outcomes were examined. RESULTS A total of 222 patients were identified (63 robotic, 159 laparoscopic). The 63 patients who received robotic surgery were matched with 61 laparoscopic patients. Cohort characteristics were similar between the two groups. In the robotic group, operative time was longer (260 vs 215 min; p = 0.000), but length of stay was shorter (6 vs 8 days; p = 0.014), and thirty-day readmission rate was lower (6.3% vs 19.7%; p = 0.033). CONCLUSIONS In this study population, robotic rectal surgery in obese patients resulted in a shorter length of stay and lower 30-day readmission rate but longer operative time when compared to laparoscopic surgery. Robotic rectal surgery in the obese may be associated with a quicker post-operative recovery and reduced morbidity profile. Larger-scale multi-centre prospective observational studies are required to validate these results.
Collapse
Affiliation(s)
- Sofoklis Panteleimonitis
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK.
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK.
| | | | - Hassan Abbas
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Ngianga Kandala
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Amjad Parvaiz
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| |
Collapse
|
34
|
Panteleimonitis S, Popeskou S, Harper M, Kandala N, Figueiredo N, Qureshi T, Parvaiz A. Minimally invasive colorectal surgery in the morbid obese: does size really matter? Surg Endosc 2018; 32:3486-3494. [PMID: 29362912 PMCID: PMC6061053 DOI: 10.1007/s00464-018-6068-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND As obesity becomes more prevalent, it presents a technical challenge for minimally invasive colorectal resection surgery. Various studies have examined the clinical outcomes of obese surgical patients. However, morbidly obese patients (BMI ≥ 35) are becoming increasingly more common. This study aims to investigate the short-term surgical outcomes of morbidly obese patients undergoing minimal-invasive colorectal surgery and compare them with both obese (30 ≤ BMI < 35) and non-obese patients (BMI < 30). METHODS Patients from three centres who received minimally invasive colorectal surgical resections between 2006 and 2016 were identified from prospectively collected databases. The baseline characteristics and surgical outcomes of morbidly obese, obese and non-obese patients were analysed. RESULTS A total of 1386 patients were identified, 84 (6%) morbidly obese, 246 (18%) obese and 1056 (76%) non-obese. Patients' baseline characteristics were similar for age, operating surgeon, surgical approach but differed in terms of ASA grade and gender. There was no difference in conversion rate, length of stay, anastomotic leak rate and 30-day readmission, reoperation and mortality rates. Operation time and blood loss were different across the 3 groups (morbidly obese vs obese vs non-obese: 185 vs 188 vs 170 min, p = 0.000; 20 vs 20 vs 10 ml, p = 0.003). In patients with malignant disease there was no difference in lymph node yield or R0 clearance. Univariate and multivariate linear regression analysis showed that for every one-unit increase in BMI operative time increases by roughly 2 min (univariate 2.243, 95% CI 1.524-2.962; multivariate 2.295; 95% CI 1.554-3.036). Univariate and multivariate binary logistic regression analyses showed that BMI does not affect conversion or morbidity and mortality. CONCLUSIONS The increased technical difficulty encountered in obese and morbidly obese patients in minimally invasive colorectal surgery results in higher operative times and blood loss, although this is not clinically significant. However, conversion rate and post-operative short-term outcomes are similar between morbidly obese, obese and non-obese patients.
Collapse
Affiliation(s)
- Sofoklis Panteleimonitis
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK.
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK.
| | | | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Ngianga Kandala
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Amjad Parvaiz
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st road, Portsmouth, PO1 2FR, UK
- Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| |
Collapse
|
35
|
Panteleimonitis S, Popeskou S, Aradaib M, Harper M, Ahmed J, Ahmad M, Qureshi T, Figueiredo N, Parvaiz A. Implementation of robotic rectal surgery training programme: importance of standardisation and structured training. Langenbecks Arch Surg 2018; 403:749-760. [PMID: 29926187 PMCID: PMC6153605 DOI: 10.1007/s00423-018-1690-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/08/2018] [Indexed: 12/20/2022]
Abstract
Purpose A structured training programme is essential for the safe adoption of robotic rectal cancer surgery. The aim of this study is to describe the training pathway and short-term surgical outcomes of three surgeons in two centres (UK and Portugal) undertaking single-docking robotic rectal surgery with the da Vinci Xi and integrated table motion (ITM). Methods Prospectively, collected data for consecutive patients who underwent robotic rectal cancer resections with the da Vinci Xi and ITM between November 2015 and September 2017 was analysed. The short-term surgical outcomes of the first ten cases of each surgeon (supervised) were compared with the subsequent cases (independent). In addition, the Global Assessment Score (GAS) forms from the supervised cases were analysed and the GAS cumulative sum (CUSUM) charts constructed to investigate the training pathway of the participating surgeons. Results Data from 82 patients was analysed. There were no conversions to open, no anastomotic leaks and no 30-day mortality. Mean operation time was 288 min (SD 63), median estimated blood loss 20 (IQR 20–20) ml and median length of stay 5 (IQR 4–8) days. Thirty-day readmission and reoperation rates were 4% (n = 3) and 6% (n = 5) respectively. When comparing the supervised cases with the subsequent solo cases, there were no statistically significant changes in any of the short-term outcomes with the exception of mean operative time, which was significantly shorter in the independent cases (311 vs 275 min, p = 0.038). GAS form analysis and GAS CUSUM charting revealed that ten proctoring cases were enough for trainee surgeons to independently perform robotic rectal resections with the da Vinci Xi. Conclusions Our results show that by applying a structured training pathway and standardising the surgical technique, the single-docking procedure with the da Vinci Xi is a valid, reproducible technique that offers good short-term outcomes in our study population.
Collapse
Affiliation(s)
- Sofoklis Panteleimonitis
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK. .,School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK.
| | | | - Mohamed Aradaib
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Jamil Ahmed
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Mukhtar Ahmad
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK.,Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Amjad Parvaiz
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK.,School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK.,Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| |
Collapse
|
36
|
Disbrow DE, Pannell SM, Shanker BA, Albright J, Wu J, Bastawrous A, Soliman M, Ferraro J, Cleary RK. The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons. JOURNAL OF SURGICAL EDUCATION 2018; 75:767-778. [PMID: 29054345 DOI: 10.1016/j.jsurg.2017.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training. DESIGN An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort. SETTING/PARTICIPANTS This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States. RESULTS The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach. CONCLUSION The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.
Collapse
Affiliation(s)
- David E Disbrow
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Stephanie M Pannell
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Beth-Ann Shanker
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Jeremy Albright
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Juan Wu
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Amir Bastawrous
- Swedish Colon and Rectal Clinic, Swedish Cancer Institute, Swedish Medical Center, Seattle, Washington
| | - Mark Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida
| | - Jane Ferraro
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Robert K Cleary
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan.
| |
Collapse
|
37
|
Nazari T, Vlieger EJ, Dankbaar MEW, van Merriënboer JJG, Lange JF, Wiggers T. Creation of a universal language for surgical procedures using the step-by-step framework. BJS Open 2018; 2:151-157. [PMID: 29951639 PMCID: PMC5989977 DOI: 10.1002/bjs5.47] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background Learning of surgical procedures is traditionally based on a master–apprentice model. Segmenting procedures into steps is commonly used to achieve an efficient manner of learning. Existing methods of segmenting procedures into steps, however, are procedure‐specific and not standardized, hampering their application across different specialties and thus worldwide uptake. The aim of this study was to establish consensus on the step‐by‐step framework for standardizing the segmentation of surgical procedures into steps. Methods An international expert panel consisting of general, gastrointestinal and oncological surgeons was approached to establish consensus on the preciseness, novelty, usefulness and applicability of the proposed step‐by‐step framework through a Delphi technique. All statements were rated on a five‐point Likert scale. A statement was accepted when the lower confidence limit was 3·00 or more. Qualitative comments were requested when a score of 3 or less was given. Results In round one, 20 of 49 experts participated. Eighteen of 19 statements were accepted; the ‘novelty’ statement needed further exploration (mean 3·05, 95 per cent c.i. 2·45 to 3·65). Based on the qualitative comments of round one, five clarifying statements were formulated for more specific statements in round two. Twenty‐two experts participated and accepted all statements. Conclusion The international expert panel consisting of general, gastrointestinal and oncological surgeons supported the preciseness, usefulness and applicability of the step‐by‐step framework. This framework creates a universal language by standardizing the segmentation of surgical procedures into step‐by‐step descriptions based on anatomical structures, and may facilitate education, communication and assessment.
Collapse
Affiliation(s)
- T Nazari
- Incision Academy Amsterdam The Netherlands.,Department of Surgery Erasmus University Medical Centre Rotterdam The Netherlands
| | | | - M E W Dankbaar
- Institute of Medical Education Research Rotterdam and Department of Education Erasmus University Medical Centre Rotterdam The Netherlands
| | - J J G van Merriënboer
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences Maastricht University Maastricht The Netherlands
| | - J F Lange
- Department of Surgery Erasmus University Medical Centre Rotterdam The Netherlands
| | - T Wiggers
- Incision Academy Amsterdam The Netherlands
| |
Collapse
|
38
|
Figueiredo N, Panteleimonitis S, Popeskou S, Cunha JF, Qureshi T, Beets GL, Heald RJ, Parvaiz A. Delaying surgery after neoadjuvant chemoradiotherapy in rectal cancer has no influence in surgical approach or short-term clinical outcomes. Eur J Surg Oncol 2018; 44:484-489. [DOI: 10.1016/j.ejso.2018.01.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 12/20/2017] [Accepted: 01/16/2018] [Indexed: 12/25/2022] Open
|
39
|
Visser E, van Rossum PSN, van Veer H, Al-Naimi K, Chaudry MA, Cuesta MA, Gisbertz SS, Gutschow CA, Hölscher AH, Luyer MDP, Mariette C, Moorthy K, Nieuwenhuijzen GAP, Nilsson M, Räsänen JV, Schneider PM, Schröder W, Cheong E, van Hillegersberg R. A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe. Dis Esophagus 2018; 31:4601761. [PMID: 29121243 DOI: 10.1093/dote/dox124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.
Collapse
Affiliation(s)
| | - P S N van Rossum
- Departments of Surgery.,Radiation Oncology, University Medical Center Utrecht, Utrecht
| | - H van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital NHS Foundation Trust
| | - M A Cuesta
- Department of Gastrointestinal Surgery, VU University Medical Center
| | - S S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam
| | - C A Gutschow
- Department of Visceral and Transplantation Surgery, University Hospital Zurich
| | - A H Hölscher
- Department of Surgery, Center for Esophageal and Gastric Surgery, and Frankfurt
| | - M D P Luyer
- Department of Surgery, Catherina Hospital Eindhoven, Eindhoven, The Netherlands
| | - C Mariette
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - K Moorthy
- Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, United Kingdom
| | | | - M Nilsson
- Department of Surgery, Karolinski University Hospital.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - J V Räsänen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - P M Schneider
- Department of Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - E Cheong
- General Surgery, Norfolk and Norwich University Hospital, Norwich
| | | |
Collapse
|
40
|
Panteleimonitis S, Harper M, Hall S, Figueiredo N, Qureshi T, Parvaiz A. Precision in robotic rectal surgery using the da Vinci Xi system and integrated table motion, a technical note. J Robot Surg 2017; 12:433-436. [PMID: 28916892 PMCID: PMC6096689 DOI: 10.1007/s11701-017-0752-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/05/2017] [Indexed: 12/26/2022]
Abstract
Robotic rectal surgery is becoming increasingly more popular among colorectal surgeons. However, time spent on robotic platform docking, arm clashing and undocking of the platform during the procedure are factors that surgeons often find cumbersome and time consuming. The newest surgical platform, the da Vinci Xi, coupled with integrated table motion can help to overcome these problems. This technical note aims to describe a standardised operative technique of single docking robotic rectal surgery using the da Vinci Xi system and integrated table motion. A stepwise approach of the da Vinci docking process and surgical technique is described accompanied by an intra-operative video that demonstrates this technique. We also present data collected from a prospectively maintained database. 33 consecutive rectal cancer patients (24 male, 9 female) received robotic rectal surgery with the da Vinci Xi during the preparation of this technical note. 29 (88%) patients had anterior resections, and four (12%) had abdominoperineal excisions. There were no conversions, no anastomotic leaks and no mortality. Median operation time was 331 (249–372) min, blood loss 20 (20–45) mls and length of stay 6.5 (4–8) days. 30-day readmission rate and re-operation rates were 3% (n = 1). This standardised technique of single docking robotic rectal surgery with the da Vinci Xi is safe, feasible and reproducible. The technological advances of the new robotic system facilitate the totally robotic single docking approach.
Collapse
Affiliation(s)
- Sofoklis Panteleimonitis
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK.
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK.
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Stuart Hall
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
| | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
- Bournemouth University School of Health and Social Care, Bournemouth, UK
| | - Amjad Parvaiz
- School of Health Sciences and Social Work, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, PO1 2FR, UK
- Poole Hospital NHS Trust, Longfleet Road, Poole, BH15 2JB, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| |
Collapse
|
41
|
Siddiqi N, Panteleimonits S, Ahmed J, Kuzu A, Parvaiz A. Role of laparoscopy in multivisceral resection for colorectal cancer - a video vignette. Colorectal Dis 2017; 19:693-694. [PMID: 28544431 DOI: 10.1111/codi.13744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/12/2017] [Indexed: 02/08/2023]
Affiliation(s)
- N Siddiqi
- Wessex Deanery, Hampshire, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - S Panteleimonits
- Wessex Deanery, Hampshire, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - J Ahmed
- Wessex Deanery, Hampshire, UK
| | - A Kuzu
- Department of Surgery, Ankara University Medical School, Ankara, Turkey
| | - A Parvaiz
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK.,Poole Hospitals NHS Foundation Trust, Poole, UK.,Champaulimaud Clinical Foundation, Lisbon, Portugal
| |
Collapse
|
42
|
Panteleimonitis S, Ahmed J, Popeskou SG, Figueiredo N, Qureshi T, Heald RJ, Parvaiz A. Tailored-made robotic abdominoperineal resection, using the da Vinci Xi, for a regrowth of rectal tumour after complete clinical response - a video vignette. Colorectal Dis 2017; 19:696-697. [PMID: 28503846 DOI: 10.1111/codi.13725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/24/2017] [Indexed: 02/08/2023]
Affiliation(s)
- S Panteleimonitis
- Poole Hospital NHS Trust, Poole, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - J Ahmed
- Poole Hospital NHS Trust, Poole, UK
| | | | | | | | - R J Heald
- Champalimaud Foundation, Lisbon, Portugal
| | - A Parvaiz
- Poole Hospital NHS Trust, Poole, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK.,Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
43
|
Panteleimonitis S, Siddiqi N, Amjad T, Figueiredo N, Parvaiz A. Laparoscopic en bloc total mesorectal excision post chemoradiotherapy - a video vignette. Colorectal Dis 2017; 19:697-698. [PMID: 28510316 DOI: 10.1111/codi.13729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/28/2017] [Indexed: 02/08/2023]
Affiliation(s)
- S Panteleimonitis
- Poole Hospital NHS Trust, Poole, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - N Siddiqi
- Poole Hospital NHS Trust, Poole, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - T Amjad
- Champalimaud Foundation, Lisbon, Portugal
| | | | - A Parvaiz
- Poole Hospital NHS Trust, Poole, UK.,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK.,Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
44
|
Curtis NJ, Davids J, Foster JD, Francis NK. Objective assessment of minimally invasive total mesorectal excision performance: a systematic review. Tech Coloproctol 2017; 21:259-268. [PMID: 28470365 DOI: 10.1007/s10151-017-1614-z] [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: 01/06/2017] [Accepted: 02/28/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Laparoscopy is widely used in colorectal practice, but recent trial results have questioned its use in rectal cancer resections. Patient outcomes are directly linked to the quality of total mesorectal excision (TME) specimen. Objective assessment of intraoperative performance could help ensure competence and delivery of optimal outcomes. Objective tools may also contribute to TME intervention trials, but their nature, structure and utilisation is unknown. AIM To systemically review the available literature to report on the available tools for the objective assessment of minimally invasive TME operative performance and their use within multicentre laparoscopic TME randomised controlled trials. METHODS A systematic search of the PubMed and Cochrane databases was performed to identify tools used in the objective intraoperative assessment of minimally invasive TME performance in accordance with the PRISMA guidelines, independently by two authors. The identified tools were then evaluated within reported TME RCTs. RESULTS A total of 8642 abstracts were screened of which 12 papers met the inclusion criteria; ten prospective observational studies, one randomised trial and one educational consensus. Eight assessment methods were described, which include formative and summative tools. The tools were mostly adaptations of colonic surgery tools based on either operative video review or post-operative trainer rating. All studies reported objective assessment of intraoperative performance was feasible, but only 126 (7%) of the 1762 included laparoscopic cases were TME. No multicentre laparoscopic TME trial reported using any objective surgical performance assessment tool. CONCLUSION Objective intraoperative laparoscopic TME performance assessment is feasible, but most of the current tools are adaptation of colonic surgery. There is a need to develop dedicated assessment tools for minimal access rectal surgery. No multicentre minimally invasive TME RCT reported using any objective assessment tool.
Collapse
Affiliation(s)
- N J Curtis
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Praed Street, London, UK
| | - J Davids
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
| | - J D Foster
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, Praed Street, London, UK
| | - N K Francis
- Clinical Research Unit, Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, Somerset, UK.
| |
Collapse
|
45
|
Iwashita Y, Hibi T, Ohyama T, Honda G, Yoshida M, Miura F, Takada T, Han HS, Hwang TL, Shinya S, Suzuki K, Umezawa A, Yoon YS, Choi IS, Huang WSW, Chen KH, Watanabe M, Abe Y, Misawa T, Nagakawa Y, Yoon DS, Jang JY, Yu HC, Ahn KS, Kim SC, Song IS, Kim JH, Yun SS, Choi SH, Jan YY, Shan YS, Ker CG, Chan DC, Wu CC, Lee KT, Toyota N, Higuchi R, Nakamura Y, Mizuguchi Y, Takeda Y, Ito M, Norimizu S, Yamada S, Matsumura N, Shindoh J, Sunagawa H, Gocho T, Hasegawa H, Rikiyama T, Sata N, Kano N, Kitano S, Tokumura H, Yamashita Y, Watanabe G, Nakagawa K, Kimura T, Yamakawa T, Wakabayashi G, Mori R, Endo I, Miyazaki M, Yamamoto M. An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:191-198. [PMID: 28196311 DOI: 10.1002/jhbp.440] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
46
|
Panteleimonitis S, Ahmed J, Ramachandra M, Farooq M, Harper M, Parvaiz A. Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study. Int J Colorectal Dis 2017; 32:241-248. [PMID: 27770247 PMCID: PMC5285426 DOI: 10.1007/s00384-016-2682-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Urological and sexual dysfunction are recognised risks of rectal cancer surgery; however, there is limited evidence regarding urogenital function comparing robotic to laparoscopic techniques. The aim of this study was to assess the urogenital functional outcomes of patients undergoing laparoscopic and robotic rectal cancer surgery. METHODS Urological and sexual functions were assessed using gender-specific validated standardised questionnaires. Questionnaires were sent a minimum of 6 months after surgery, and patients were asked to report their urogenital function pre- and post-operatively, allowing changes in urogenital function to be identified. Questionnaires were sent to 158 patients (89 laparoscopy, 69 robotic) of whom 126 (80 %) responded. Seventy-eight (49 male, 29 female) of the responders underwent laparoscopic and 48 (35 male, 13 female) robotic surgery. RESULTS Male patients in the robotic group deteriorated less across all components of sexual function and in five components of urological function. Composite male urological and sexual function score changes from baseline were better in the robotic cohort (p < 0.001). In females, there was no difference between the two groups in any of the components of urological or sexual function. However, composite female urological function score change from baseline was better in the robotic group (p = 0.003). CONCLUSION Robotic rectal cancer surgery might offer better post-operative urological and sexual outcomes compared to laparoscopic surgery in male patients and better urological outcomes in females. Larger scale, prospective randomised control studies including urodynamic assessment of urogenital function are required to validate these results.
Collapse
Affiliation(s)
- Sofoklis Panteleimonitis
- Department of Minimally Invasive Colorectal Unit, Queen Alexandra Hospital NHS Trust, Portsmouth, UK ,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - Jamil Ahmed
- Department of Minimally Invasive Colorectal Unit, Queen Alexandra Hospital NHS Trust, Portsmouth, UK
| | - Meghana Ramachandra
- Department of Minimally Invasive Colorectal Unit, Queen Alexandra Hospital NHS Trust, Portsmouth, UK
| | - Muhammad Farooq
- Department of Minimally Invasive Colorectal Unit, Queen Alexandra Hospital NHS Trust, Portsmouth, UK
| | - Mick Harper
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - Amjad Parvaiz
- Department of Minimally Invasive Colorectal Unit, Queen Alexandra Hospital NHS Trust, Portsmouth, UK ,School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK ,Colorectal Cancer Unit, Champalimaud Clinical Foundation, Lisbon, Portugal
| |
Collapse
|
47
|
Foster JD, Ewings P, Falk S, Cooper EJ, Roach H, West NP, Williams-Yesson BA, Hanna GB, Francis NK. Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial. Tech Coloproctol 2016; 20:683-93. [PMID: 27510524 DOI: 10.1007/s10151-016-1514-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal time of rectal resection after long-course chemoradiotherapy (CRT) remains unclear. A feasibility study was undertaken for a multi-centre randomized controlled trial evaluating the impact of the interval after chemoradiotherapy on the technical complexity of surgery. METHODS Patients with rectal cancer were randomized to either a 6- or 12-week interval between CRT and surgery between June 2012 and May 2014 (ISRCTN registration number: 88843062). For blinded technical complexity assessment, the Observational Clinical Human Reliability Analysis technique was used to quantify technical errors enacted within video recordings of operations. Other measured outcomes included resection completeness, specimen quality, radiological down-staging, tumour cell density down-staging and surgeon-reported technical complexity. RESULTS Thirty-one patients were enrolled: 15 were randomized to 6 and 16-12 weeks across 7 centres. Fewer eligible patients were identified than had been predicted. Of 23 patients who underwent resection, mean 12.3 errors were observed per case at 6 weeks vs. 10.7 at 12 weeks (p = 0.401). Other measured outcomes were similar between groups. CONCLUSIONS The feasibility of measurement of operative performance of rectal cancer surgery as an endpoint was confirmed in this exploratory study. Recruitment of sufficient numbers of patients represented a challenge, and a proportion of patients did not proceed to resection surgery. These results suggest that interval after CRT may not substantially impact upon surgical technical performance.
Collapse
Affiliation(s)
- J D Foster
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - P Ewings
- Southwest Research Design Service, Taunton and Somerset NHS Trust, Taunton, UK
| | - S Falk
- University Hospitals Bristol, Upper Maudlin Street, Bristol, UK
| | - E J Cooper
- Department of Pathology, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - H Roach
- University Hospitals Bristol, Upper Maudlin Street, Bristol, UK
| | - N P West
- Leeds Institute of Cancer and Pathology, School of Medicine, St James's University Hospital, University of Leeds, Leeds, UK
| | - B A Williams-Yesson
- Department of Research and Development, St Mary's Hospital, Imperial College, London, UK
| | - G B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - N K Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
| | | |
Collapse
|
48
|
Defining Honors in the Surgery Clerkship. J Am Coll Surg 2016; 223:665-9. [PMID: 27481094 DOI: 10.1016/j.jamcollsurg.2016.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although highly influential, no published criteria exist that define who should receive the highest grade in the core surgery clerkship ("honors"). Therefore, significant variability exists in how this evaluation is assigned. Identifying the critical characteristics of the student receiving this grade can improve its usefulness in residency selection, class standing, and direct students' efforts. The purpose of this study was to attain expert consensus on the characteristics of an honors student in the core surgery clerkship. STUDY DESIGN A 3-round modified Delphi technique was used in 2 parallel cycles to obtain expert consensus from the major stakeholders-program directors and clerkship directors in surgery. Experts were recruited from across the United States, although not from the same institutions. The 2 consensus lists were evaluated for congruency. RESULTS All 15 of the invited clerkship directors and 14 of 15 invited program directors participated. A total of 65 unique characteristics were submitted by program directors and consensus was reached on 23. Clerkship directors submitted 62 characteristics and achieved agreement on 22. Ten of the final characteristics were identical between the 2 groups. These were communication skills, "shelf" exam score, synthetic ability (organizing data into meaningful care plans), absence of professionalism issues, outstanding work ethic, taking advantage of learning opportunities, accurate and complete history and physicals, enthusiasm, becoming an essential member of the care team, and outstanding clinical acumen. CONCLUSIONS Expert consensus on the characteristics of an honors student in the core surgery clerkship was achieved. By using these criteria, the honors grade becomes emblematic of these 10 characteristics. This might reduce grade inflation within and between institutions, provide program directors with a consistent and reliable assessment of excellence, and effectively direct student efforts.
Collapse
|
49
|
Haugvik SP, Groven S, Bondi J, Vågan T, Brynhildsvoll SO, Olsen OC. A critical appraisal of transanal minimally invasive surgery (TAMIS) in the treatment of rectal adenoma: a 4-year experience with 51 cases. Scand J Gastroenterol 2016; 51:855-9. [PMID: 27000415 DOI: 10.3109/00365521.2016.1157891] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to describe feasibility, postoperative morbidity, and histological outcome of transanal minimally-invasive surgery (TAMIS) in patients with rectal adenoma. MATERIAL AND METHODS All patients who underwent TAMIS at a single institution from December 2011 to December 2015 were retrospectively included in the study. Feasibility was based on tumor size, distance of tumor from the anal verge, operative time, and hospital stay. Thirty-day morbidity was defined by the revised Accordion Classification system. Histological outcome included microscopic resection margin status, specimen fragmentation status, and grading of dysplasia in rectal adenoma. RESULTS A total of 51 patients with rectal adenoma underwent TAMIS. The median tumor diameter was 32 (4-60) mm and the median distance from the anal verge 8 (3-14) cm. Median operative time was 40 (13-116) min and median length of hospital stay was 1 (0-25) days. Overall morbidity was 12% (four grade 1, one grade 2, and one grade 3 complications). 22% had a positive resection margin, whereas 31% had an indefinable resection margin status mostly due to tissue fragmentation. Median follow-up time was 7 (0-40) months. CONCLUSIONS TAMIS is a challenging surgical technique for treatment of rectal adenoma. Our initial experience among 51 patients resulted in a high proportion of positive resection margins and a high fragmentation rate. The role of TAMIS in the treatment of rectal adenoma is to be defined through comparative studies.
Collapse
Affiliation(s)
- Sven-Petter Haugvik
- a Department of Surgery , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| | - Sigrid Groven
- a Department of Surgery , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| | - Johan Bondi
- a Department of Surgery , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| | - Torolf Vågan
- b Department of Pathology , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| | - Stig Ove Brynhildsvoll
- b Department of Pathology , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| | - Ole Christian Olsen
- a Department of Surgery , Drammen Hospital, Vestre Viken Hospital Trust , Drammen , Norway
| |
Collapse
|
50
|
Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients. Int J Colorectal Dis 2016; 31:1179-87. [PMID: 27080161 DOI: 10.1007/s00384-016-2586-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Because there are few comparative studies of open, laparoscopy-assisted (LA), and robot-assisted (RA) total mesorectal excision (TME) for rectal cancer, we aimed to compare these three procedures in terms of sphincter-saving operation (SSO) achievement, surgical complications, and early oncological outcomes. METHODS The short-term outcomes of 2114 patients with rectal cancer consecutively enrolled between July 2010 and February 2015 at Asan Medical Center (Seoul, Korea) were retrospectively evaluated. Patients underwent either open, LA, or RA TME (n = 1095, 486, and 533, respectively) performed by experienced surgeons. RESULTS RA TME was a significant determinant of SSO in multivariate analysis that included potential variables such as tumor location and T4 category (odds ratio, 2.458; 95 % confidence interval, 1.497-4.036; p < 0.001). The cumulative rates of 3-year local recurrence, overall survival, and disease-free survival did not differ among the three groups: 2.5-3.4, 91.9-94.6, and 82.2-83.1 % (p = 0.85, 0.352, and 0.944, respectively). Early general surgical complications occurred more frequently in the open group than in the LA and RA groups (19.3 versus 13.0 versus 12.2 %, p < 0.001), specifically ileus and wound infection. CONCLUSIONS There were no significant differences in 3-year survival outcomes and local recurrence among open, LA, and RA TME. RA TME is useful for SSO achievement, regardless of advanced stage and location of rectal cancer. The open procedure had a slightly but significantly higher incidence of postoperative complications than LA and RA.
Collapse
|