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Shah MF, Nasir IUI, Ahmad R, Ahmad S, Amjad A, Zaineb KB, Rehman R. Short-Term Outcomes of First 100 Laparoscopic Colorectal Surgeries at a Newly Developed Surgical Setup at Peshawar. Cureus 2024; 16:e53588. [PMID: 38449997 PMCID: PMC10915358 DOI: 10.7759/cureus.53588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) has risen steadily, necessitating innovative strategies for diagnosis and treatment. Minimally invasive surgery, exemplified by laparoscopic techniques, has emerged as a transformative approach in colorectal surgical practices. Laparoscopy offers advantages such as improved aesthetic outcomes, reduced post-operative pain, early patient mobilization, and shorter hospital stays. OBJECTIVE This study aims to present the short-term surgical outcomes of the first 100 elective laparoscopic CRC resections performed at a newly established tertiary care cancer center in Peshawar, Pakistan. MATERIALS AND METHODS Data were prospectively collected for CRC resections performed between April 2021 and February 2022. The study included patients above 18 years of age with biopsy-proven CRC. Surgical procedures were performed by two dedicated colorectal surgeons trained in minimally invasive surgery. Patient demographics, pre-operative factors, intraoperative parameters, and post-operative outcomes were systematically recorded and analyzed. RESULTS Among the 100 cases included in the study, laparoscopic colorectal surgeries were successfully performed without any conversions to open surgery. The mean age of the study population was 52.5 years, with a male-to-female ratio of 2:1. The majority of cases were colon (48%) and anorectal cancers (52%). The mean lymph node yield was 18.29 (range 6-49). Only one patient required a re-look laparoscopy for a pelvic hematoma, and overall mortality was reported at 1%. CONCLUSION Laparoscopic colorectal surgery is a safe and effective treatment option for elective colorectal operations with minimal post-operative complications and favorable short-term outcomes.
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Affiliation(s)
- Muhammad F Shah
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Irfan Ul Islam Nasir
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Riaz Ahmad
- Colorectal Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Sajjad Ahmad
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Aalia Amjad
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Khush Bakht Zaineb
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | - Romana Rehman
- Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
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Thompson HM, Williams H, Omer DM, Yuval JB, Verheij FS, Fiasconaro M, Widmar M, Wei IH, Pappou EP, Smith JJ, Nash GM, Weiser MR, Paty PB, Shahrokni A, Garcia-Aguilar J. Comparison of short-term outcomes and survival between minimally invasive colectomy and open colectomy in patients 80 years of age and older. J Robot Surg 2023; 17:1857-1865. [PMID: 37022559 PMCID: PMC10527224 DOI: 10.1007/s11701-023-01575-1] [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: 02/06/2023] [Accepted: 03/12/2023] [Indexed: 04/07/2023]
Abstract
We investigated the short- and long-term outcomes of patients 80 years of age and older with colon cancer who underwent robotic colectomy versus laparoscopic colectomy. Data for patients treated at a comprehensive cancer center between January 2006 and November 2018 were collected retrospectively. Outcomes from minimally invasive laparoscopic or robotic colectomy were compared. Survival was analyzed by the Kaplan-Meier method with significance evaluated by the log-rank test. The laparoscopic (n = 104) and the robotic (n = 75) colectomy groups did not differ across baseline characteristics. Patients who underwent a robotic colectomy had a shorter median length of hospital stay (5 versus 6 days; p < 0.001) and underwent fewer conversions to open surgery (3% versus 17%; p = 0.002) compared to the laparoscopic cohort. The groups did not differ in postoperative complication rates, overall survival or disease-free survival. Elderly patients undergoing robotic colectomy for colon cancer have a shorter hospital stay and lower rates of conversion without compromise to oncologic outcomes.
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Affiliation(s)
- Hannah M Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Williams
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dana M Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Floris S Verheij
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Armin Shahrokni
- Department of Medicine, Geriatrics Service, Jersey Shore Medical Center, Neptune Township, NJ, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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3
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Mascagni P, Alapatt D, Sestini L, Altieri MS, Madani A, Watanabe Y, Alseidi A, Redan JA, Alfieri S, Costamagna G, Boškoski I, Padoy N, Hashimoto DA. Computer vision in surgery: from potential to clinical value. NPJ Digit Med 2022; 5:163. [PMID: 36307544 PMCID: PMC9616906 DOI: 10.1038/s41746-022-00707-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Hundreds of millions of operations are performed worldwide each year, and the rising uptake in minimally invasive surgery has enabled fiber optic cameras and robots to become both important tools to conduct surgery and sensors from which to capture information about surgery. Computer vision (CV), the application of algorithms to analyze and interpret visual data, has become a critical technology through which to study the intraoperative phase of care with the goals of augmenting surgeons' decision-making processes, supporting safer surgery, and expanding access to surgical care. While much work has been performed on potential use cases, there are currently no CV tools widely used for diagnostic or therapeutic applications in surgery. Using laparoscopic cholecystectomy as an example, we reviewed current CV techniques that have been applied to minimally invasive surgery and their clinical applications. Finally, we discuss the challenges and obstacles that remain to be overcome for broader implementation and adoption of CV in surgery.
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Affiliation(s)
- Pietro Mascagni
- Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy. .,IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France. .,Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.
| | - Deepak Alapatt
- ICube, University of Strasbourg, CNRS, IHU, Strasbourg, France
| | - Luca Sestini
- ICube, University of Strasbourg, CNRS, IHU, Strasbourg, France.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Maria S Altieri
- Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.,Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Amin Madani
- Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.,Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Yusuke Watanabe
- Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.,Department of Surgery, University of Hokkaido, Hokkaido, Japan
| | - Adnan Alseidi
- Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.,Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jay A Redan
- Department of Surgery, AdventHealth-Celebration Health, Celebration, FL, USA
| | - Sergio Alfieri
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ivo Boškoski
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nicolas Padoy
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,ICube, University of Strasbourg, CNRS, IHU, Strasbourg, France
| | - Daniel A Hashimoto
- Global Surgical Artificial Intelligence Collaborative, Toronto, ON, Canada.,Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Hou J, Zhao R, Cai T, Beaulieu-Jones B, Seyok T, Dahal K, Yuan Q, Xiong X, Bonzel CL, Fox C, Christiani DC, Jemielita T, Liao KP, Liaw KL, Cai T. Temporal Trends in Clinical Evidence of 5-Year Survival Within Electronic Health Records Among Patients With Early-Stage Colon Cancer Managed With Laparoscopy-Assisted Colectomy vs Open Colectomy. JAMA Netw Open 2022; 5:e2218371. [PMID: 35737384 PMCID: PMC9227003 DOI: 10.1001/jamanetworkopen.2022.18371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Temporal shifts in clinical knowledge and practice need to be adjusted for in treatment outcome assessment in clinical evidence. OBJECTIVE To use electronic health record (EHR) data to (1) assess the temporal trends in treatment decisions and patient outcomes and (2) emulate a randomized clinical trial (RCT) using EHR data with proper adjustment for temporal trends. DESIGN, SETTING, AND PARTICIPANTS The Clinical Outcomes of Surgical Therapy (COST) Study Group Trial assessing overall survival of patients with stages I to III early-stage colon cancer was chosen as the target trial. The RCT was emulated using EHR data of patients from a single health care system cohort who underwent colectomy for early-stage colon cancer from January 1, 2006, to December 31, 2017, and were followed up to January 1, 2020, from Mass General Brigham. Analyses were conducted from December 2, 2019, to January 24, 2022. EXPOSURES Laparoscopy-assisted colectomy (LAC) vs open colectomy (OC). MAIN OUTCOMES AND MEASURES The primary outcome was 5-year overall survival. To address confounding in the emulation, pretreatment variables were selected and adjusted. The temporal trends were adjusted by stratification of the calendar year when the colectomies were performed with cotraining across strata. RESULTS A total of 943 patients met key RCT eligibility criteria in the EHR emulation cohort, including 518 undergoing LAC (median age, 63 [range, 20-95] years; 268 [52%] women; 121 [23%] with stage I, 165 [32%] with stage II, and 232 [45%] with stage III cancer; 32 [6%] with colon adhesion; 278 [54%] with right-sided colon cancer; 18 [3%] with left-sided colon cancer; and 222 [43%] with sigmoid colon cancer) and 425 undergoing OC (median age, 65 [range, 28-99] years; 223 [52%] women; 61 [14%] with stage I, 153 [36%] with stage II, and 211 [50%] with stage III cancer; 39 [9%] with colon adhesion; 202 [47%] with right-sided colon cancer; 39 [9%] with left-sided colon cancer; and 201 [47%] with sigmoid colon cancer). Tests for temporal trends in treatment assignment (χ2 = 60.3; P < .001) and overall survival (χ2 = 137.2; P < .001) were significant. The adjusted EHR emulation reached the same conclusion as the RCT: LAC is not inferior to OC in overall survival rate with risk difference at 5 years of -0.007 (95% CI, -0.070 to 0.057). The results were consistent for stratified analysis within each temporal period. CONCLUSIONS AND RELEVANCE These findings suggest that confounding bias from temporal trends should be considered when conducting clinical evidence studies with long time spans. Stratification of calendar time and cotraining of models is one solution. With proper adjustment, clinical evidence may supplement RCTs in the assessment of treatment outcome over time.
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Affiliation(s)
- Jue Hou
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rachel Zhao
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tianrun Cai
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Brett Beaulieu-Jones
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Thany Seyok
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Kumar Dahal
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Qianyu Yuan
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Xin Xiong
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Clara-Lea Bonzel
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - David C. Christiani
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Katherine P. Liao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | | | - Tianxi Cai
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
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5
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Logie K, Doumouras AG, Springer JE, Eskicioglu C, Hong D. Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites. Dis Colon Rectum 2021; 64:1232-1239. [PMID: 33960327 DOI: 10.1097/dcr.0000000000002034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors. OBJECTIVE The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use. DESIGN This was a population-based retrospective analysis from April 2008 to March 2015. SETTINGS All Canadian provinces (excluding Quebec) were included. PATIENTS The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center. RESULTS A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001). LIMITATIONS Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias. CONCLUSIONS Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595. VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.
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Affiliation(s)
- Kathleen Logie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
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Swords DS, Bednarski BK, Messick CA, Tillman MM, Chang GJ, You YN. Quality and Location of the Surgical Episode Mediate a Large Proportion of Socioeconomic-Based Survival Disparities in Patients with Resected Stage I-III Colon Cancer. Ann Surg Oncol 2021; 29:706-716. [PMID: 34406541 DOI: 10.1245/s10434-021-10643-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/24/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Lower socioeconomic status (SES) is associated with shorter overall survival (OS) in patients with locoregional colon cancer. We aimed to estimate: (1) the proportion of SES-based OS disparities mediated by disparities in the quality and location of surgical treatment in patients with resected stage I-III colon cancer and (2) the relative importance of components of surgical quality. PATIENTS AND METHODS We examined patients ages 18-80 years with resected stage I-III colon adenocarcinoma using the 2010-2016 National Cancer Database. SES was defined at the zip code level. Inverse odds weighting mediation analysis was used to estimate the proportion mediated (PM) for nine treatment quality-related and facility-related factors and composite PMs in models including all nine mediators. Models compared high SES patients with each lower SES stratum. RESULTS Among 171,009 patients, 5-year OS increased from 70.4% in low SES patients to 78.1% in high SES. When high SES patients were compared with low, lower-middle, and upper-middle SES patients, PM ranges among lower SES strata were: minimally invasive surgery 16.0-16.6%, lymph nodes examined 7.7-9.6%, positive margins 3.8-6.5%, length of stay 16.7-28.1%, readmissions insignificant to 3.7%, treatment at > 1 CoC facility 2.7-3.1%, facility type insignificant to 7.3%, facility volume 2.9-8.2%, and adjusted facility 90-day mortality rates 33.2-42.8%. Composite PMs were 76.9% (95% CI 61.3%, 92.4%) for low SES, 68.7% (95% CI 56.4%, 81.1%) for lower-middle SES, and 60.9% (95% CI 43.1%, 78.6%) for upper-middle SES. CONCLUSIONS These data suggest that improving the quality of the surgical episode for disadvantaged patients undergoing resection for locoregional colon cancer could decrease SES-based survival disparities by over half.
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Affiliation(s)
- Douglas S Swords
- Department of Surgical Oncology, University of Texas MD Anderson Cancer, Houston, TX, USA.
| | - Brian K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer, Houston, TX, USA.,Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Craig A Messick
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Matthew M Tillman
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - George J Chang
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Y Nancy You
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer, Houston, TX, USA
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7
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Gkionis IG, Flamourakis ME, Tsagkataki ES, Kaloeidi EI, Spiridakis KG, Kostakis GE, Alegkakis AK, Christodoulakis MS. Multidimensional analysis of the learning curve for laparoscopic colorectal surgery in a regional hospital: the implementation of a standardized surgical procedure counterbalances the lack of experience. BMC Surg 2020; 20:308. [PMID: 33267802 PMCID: PMC7709341 DOI: 10.1186/s12893-020-00975-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique. Methods From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 – group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups. Results There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083). Conclusions Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.
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Affiliation(s)
- Ioannis G Gkionis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece.
| | - Mathaios E Flamourakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni S Tsagkataki
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Eleni I Kaloeidi
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Konstantinos G Spiridakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | - Georgios E Kostakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
| | | | - Manousos S Christodoulakis
- Department of General Surgery, Venizeleio General Hospital, Leoforos Knossou 44, Heraklion, Crete, Greece
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8
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Effects of laparoscopic vs open abdominal surgery on costs and hospital readmission rate and its effect modification by surgeons' case volume. Surg Endosc 2020; 34:1-12. [PMID: 31659507 DOI: 10.1007/s00464-019-07222-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopy provides a minimally invasive alternative to open abdominal surgery. Current data describing its association with hospital readmission and costs in relation to surgeon laparoscopic case volume is limited to smaller databases and subsets of operations. METHODS This retrospective cohort study of 23,285 adult abdominal operations from 2007 to 2015 compares 30-day readmission rate and costs between laparoscopic and open abdominal operations and examines effect modification by surgeon laparoscopic case volume. Outcomes were all-cause hospital readmission within 30 days after discharge and index hospital admission cost. RESULTS All-cause hospital readmission rates were significantly lower after laparoscopic abdominal operations compared with open operations (adjusted odds ratio [aOR] 0.56, 95% CI 0.46-0.69, p < 0.001) with a difference in readmission risk attributable to laparoscopic approach of - 4.0% (95% CI - 5.4 to - 2.6%) in complete-case analysis. Among surgeons with a high laparoscopic case volume, the estimated difference in readmission risk through laparoscopy was magnified (- 5.8%, 95% CI - 7.5 to - 4.1%) compared to low surgeon laparoscopic case volume (- 2.9%, 95% CI - 4.8 to -1.1%, p for interaction = 0.005). The estimated difference in costs of the index hospital admission attributable to laparoscopic approach was - $3869 (95% CI - $4200 to - $3538; adjusted incidence rate ratio 0.77, 95% CI 0.75-0.79, p < 0.001). Laparoscopy was followed by significantly lower rates of readmissions related to gastrointestinal (aOR 0.68, 95% CI 0.55-0.85, p = 0.001), wound complications (infection: aOR 0.33, 95% CI 0.23-0.47, p < 0.001; non-infectious: aOR 0.47, 95% CI 0.30-0.74, p = 0.001), and malignancy (aOR 0.68, 95% CI 0.55-0.85, p < 0.001). The findings remain robust after multiple imputation and sensitivity analyses. CONCLUSIONS Laparoscopy versus open abdominal surgery is associated with reduced hospital readmissions related to malignancy, gastrointestinal, and wound complications. Effect modification by higher laparoscopy case volume argues for continued proliferation of laparoscopy in abdominal surgeries.
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Role of Emergency Laparoscopic Colectomy for Colorectal Cancer: A Population-based Study in England. Ann Surg 2020; 270:172-179. [PMID: 29621034 DOI: 10.1097/sla.0000000000002752] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate factors associated with the use of laparoscopic surgery and the associated postoperative outcomes for urgent or emergency resection of colorectal cancer in the English National Health Service. SUMMARY OF BACKGROUND DATA Laparoscopy is increasingly used for elective colorectal cancer surgery, but uptake has been limited in the emergency setting. METHODS Patients recorded in the National Bowel Cancer Audit who underwent urgent or emergency colorectal cancer resection between April 2010 and March 2016 were included. A multivariable multilevel logistic regression model was used to estimate odds ratios (ORs) of undergoing laparoscopic resection and postoperative outcome according to approach. RESULTS There were 15,516 patients included. Laparoscopy use doubled from 15.1% in 2010 to 30.2% in 2016. Laparoscopy was less common in patients with poorer physical status [American Society of Anaesthesiologists (ASA) 4/5 vs 1, OR 0.29 (95% confidence interval, 95% CI 0.23-0.37), P < 0.001] and more advanced T-stage [T4 vs T0-T2, OR 0.28 (0.23-0.34), P < 0.001] and M-stage [M1 vs M0, OR 0.85 (0.75-0.96), P < 0.001]. Age, socioeconomic deprivation, nodal stage, hospital volume, and a dedicated colorectal emergency service were not associated with laparoscopy. Laparoscopic patients had a shorter length of stay [median 8 days (interquartile range (IQR) 5 to 15) vs 12 (IQR 8 to 21), adjusted mean difference -3.67 (-4.60 to 2.74), P < 0.001], and lower 90-day mortality [8.1% vs 13.0%; adjusted OR 0.78 (0.66-0.91), P = 0.004] than patients undergoing open resection. There was no significant difference in rates of readmission or reoperation by approach. CONCLUSION The use of laparoscopic approach in the emergency resection of colorectal cancer is linked to a shorter length of hospital stay and reduced postoperative mortality.
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10
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Springer JE, Doumouras AG, Eskicioglu C, Hong D. Regional Variation in the Utilization of Laparoscopy for the Treatment of Rectal Cancer: The Importance of Fellowship Training Sites. Ann Surg Oncol 2019; 27:2478-2486. [DOI: 10.1245/s10434-019-08115-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Indexed: 01/22/2023]
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11
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Wynn-Jones W, Koehlmoos TP, Tompkins C, Navathe A, Lipsitz S, Kwon NK, Learn PA, Madsen C, Schoenfeld A, Weissman JS. Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform. BMC Health Serv Res 2019; 19:877. [PMID: 31752866 PMCID: PMC6873455 DOI: 10.1186/s12913-019-4729-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 11/07/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy. METHODS Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure. RESULTS After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG). CONCLUSIONS This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.
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Affiliation(s)
- W. Wynn-Jones
- Centre for Surgery and Public Health, Brigham and Women’s Hospital, 1620 Tremont Street, 1 Brigham Circle, Boston, MA 02120 USA
| | - T. P. Koehlmoos
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20184 USA
| | - C. Tompkins
- Heller Graduate School, Brandeis University, 415 South St., Waltham, MA 02354 USA
| | - A. Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - S. Lipsitz
- Division of General Internal Medicine and Center for Surgery and Public Health, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - N. K. Kwon
- Centre for Surgery and Public Health, Brigham and Women’s Hospital, Boston, USA
| | - P. A. Learn
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - C. Madsen
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - A. Schoenfeld
- Department of Orthopaedic Surgery Center for Surgery and Public health Brigham and Women’s Hospital Harvard Medical School, Boston, USA
| | - J. S. Weissman
- (Health Policy) Harvard Medical School, Center for Surgery and Public Health, Boston, USA
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12
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Chiu CC, Hsu WT, Choi JJ, Galm B, Lee MTG, Chang CN, Liu CYC, Lee CC. Comparison of outcome and cost between the open, laparoscopic, and robotic surgical treatments for colon cancer: a propensity score-matched analysis using nationwide hospital record database. Surg Endosc 2019; 33:3757-3765. [PMID: 30675661 DOI: 10.1007/s00464-019-06672-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are limited studies that compare the cost and outcome of robotic-assisted surgery to open and laparoscopic surgery for colon cancer treatment. We aimed to compare the three surgical modalities for colon cancer treatment. METHODS We performed a cohort study using the population-based Nationwide Inpatient Sample database. Patients with a primary diagnosis of colon cancer who underwent robotic, laparoscopic, or open surgeries between 2008 and 2014 were eligible for enrollment. We compared in-hospital mortality, complications, length of hospital stay, and cost for patients undergoing one of these three procedures using a multivariate adjusted logistic regression analysis and propensity score matching. RESULTS Of the 531,536 patients undergoing surgical treatment for colon cancer during the study period, 348,645 (65.6%) patients underwent open surgeries, 174,748 (32.9%) underwent laparoscopic surgeries, and 8143 (1.5%) underwent robotic surgeries. In-hospital mortality, length of hospital stay, wound complications, general medical complications, general surgical complications, and costs of the three surgical treatment modalities. Compared to those undergoing laparoscopic surgery, patients undergoing open surgery had a higher mortality rate (OR 2.98, 95% CI 2.61-3.40), more general medical complications (OR 1.77, 95% CI 1.67-1.87), a longer length of hospital stay (6.60 vs. 4.36 days), and higher total cost ($18,541 vs. $14,487) in the propensity score matched cohort. Mortality rate and general medical complications were equivalent in the laparoscopic and robotic surgery groups, but the median cost was lower in the laparoscopic group ($14641 vs. $16,628 USD). CONCLUSIONS Laparoscopic colon cancer surgery was associated with a favourable short-term outcome and lower cost compared with open surgery. Robot-assisted surgery had comparable outcomes but higher cost as compared to laparoscopic surgery.
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Affiliation(s)
- Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Liouying, Tainan, Taiwan, Republic of China
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan, Republic of China
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - James J Choi
- Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Brandon Galm
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meng-Tse Gabriel Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan, Republic of China
| | - Chia-Na Chang
- Department of Radiation Oncology, Wan-Fang Hospital, Taipei, Taiwan, Republic of China
| | - Chia-Yu Carolyn Liu
- School of Health, McTimoney College of Chiropractic, BPP University, Abingdon, Oxfordshire, UK
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan, Republic of China.
- Health Data Science Research Group, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan, Republic of China.
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13
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Clapp B, Klingsporn W, Harper B, Swinney IL, Dodoo C, Davis B, Tyroch A. Utilization of Laparoscopic Colon Surgery in the Texas Inpatient Public Use Data File (PUDF). JSLS 2019; 23:JSLS.2019.00032. [PMID: 31488941 PMCID: PMC6708411 DOI: 10.4293/jsls.2019.00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Laparoscopic surgery has become the standard of care for the most common surgical procedures performed. However, laparoscopic techniques have not reached this same penetrance in colorectal surgery. We wanted to determine the percentage of colon operations performed in Texas that were done via laparoscopic, robotic and open techniques. Methods: The Texas Inpatient Public Use Data File (PUDF) was queried using ICD-9-CM diagnostic and procedure codes to determine overall utilization of laparoscopic colectomies (LC) in Texas between 2013-14 for reporting facilities. We specifically looked at cost and the length of stay for LC, open colectomy (OC) and robotic assisted colectomy (RAC). Results: In the state of Texas between 2013-14 there were 20,454 colectomies performed. Of these 12,328 (60.3%) were OC, 7,536 (36.8%) were LC, and 590 (3.9%) were RAC. Average total cost was $117,113 for OC, $75,741.9 for LC, and $81,996.2 for RAC. Average length of stay for each technique was 10.6 days for OC, 6.1 days for LC, and 5.1 days for RAC. The risk of a postoperative complication occurring was higher in the open procedure than a laparoscopic procedure. Conclusions: LC accounted for only 36.8% of all colectomies performed in Texas between 2013-14. OC costs twice as much as LC and increased the length of stay by nearly 4 d. LC and RAC are both associated with significantly less cost and length of stay for patients undergoing surgery, while lowering perioperative complications. Disclosures: None of the authors have any relevant disclosures.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - William Klingsporn
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - Brittany Harper
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - Ira L Swinney
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - Christopher Dodoo
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - Brian Davis
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
| | - Alan Tyroch
- Department of Surgery, TX Tech HSC Paul Foster School of Medicine, El Paso TX
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14
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Osagiede O, Spaulding AC, Cochuyt JJ, Naessens J, Merchea A, Colibaseanu DT. Trends in the Use of Laparoscopy and Robotics for Colorectal Cancer in Florida. J Laparoendosc Adv Surg Tech A 2019; 29:926-933. [PMID: 31094645 DOI: 10.1089/lap.2019.0016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.
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Affiliation(s)
| | - Aaron C Spaulding
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Jordan J Cochuyt
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - James Naessens
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Amit Merchea
- 1 Department of Surgery and Mayo Clinic, Jacksonville, Florida
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15
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Sastow DL, White RS, Mauer E, Chen Y, Gaber-Baylis LK, Turnbull ZA. The Disparity of Care and Outcomes for Medicaid Patients Undergoing Colectomy. J Surg Res 2019; 235:190-201. [DOI: 10.1016/j.jss.2018.09.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/10/2018] [Accepted: 09/19/2018] [Indexed: 01/05/2023]
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16
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Osagiede O, Spaulding AC, Cochuyt JJ, Naessens JM, Merchea A, Kasi PM, Crandall M, Colibaseanu DT. Disparities in minimally invasive surgery for colorectal cancer in Florida. Am J Surg 2018; 218:293-301. [PMID: 30503514 DOI: 10.1016/j.amjsurg.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida. METHODS Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach. RESULTS Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001). CONCLUSIONS Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.
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Affiliation(s)
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Amit Merchea
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Pashtoon M Kasi
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Marie Crandall
- Department of Surgery, University of Florida, Jacksonville, FL, USA
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17
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Byrne BE, Vincent CA, Faiz OD. Inequalities in Implementation and Different Outcomes During the Growth of Laparoscopic Colorectal Cancer Surgery in England: A National Population-Based Study from 2002 to 2012. World J Surg 2018; 42:3422-3431. [PMID: 29633102 PMCID: PMC6132863 DOI: 10.1007/s00268-018-4615-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AIM Laparoscopic colorectal cancer surgery has developed from unproven technique to mainstay of treatment. This study examined the application and relative outcomes of laparoscopic and open colorectal cancer surgery over time, as laparoscopic uptake and experience have grown. METHODS Adults undergoing elective laparoscopic and open colorectal cancer surgery in the English NHS during 2002-2012 were included. Age, sex, Charlson Comorbidity Index and Index of Multiple Deprivation were compared over time. Post-operative 30-day mortality, length of stay, failure to rescue reoperation and the associated mortality rate were examined. RESULTS Laparoscopy rates rose from 1.1 to 50.8%. Patients undergoing laparoscopic surgery had lower comorbidity by 0.24 points (95% confidence intervals (CI) 0.20-0.27) and lower socioeconomic deprivation by 0.16 deciles (95% CI 0.12-0.20) than those having open procedures. Overall mortality fell by 48.0% from 2002-2003 to 2011-2002 and was 37.8% lower after laparoscopic surgery. Length of stay and mortality after surgical re-intervention also fell. However, re-intervention rates were higher after laparoscopic procedures by 7.8% (95% CI 0.9-15.2%). CONCLUSIONS There was clear and persistent inequality in the application of laparoscopic colorectal cancer surgery during this study. Further work must explore and remedy inequalities to maximise patient benefit. Higher re-intervention rates after laparoscopy are unexplained and differ from randomized controlled trials. This may reflect differences in surgeons and practice between research and usual care settings and should be further investigated.
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Affiliation(s)
- B E Byrne
- Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK.
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - C A Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - O D Faiz
- Surgical Epidemiology, Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
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18
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Nam S, Choi YJ, Hong Y, Kang JG. Skip metastasis to portocaval and retropancreatic space in T2 cecal cancer without regional and principle lymph node involvement. ACTA ACUST UNITED AC 2018. [DOI: 10.14216/kjco.18010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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19
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What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review. Int J Colorectal Dis 2018; 33:663-681. [PMID: 29623415 DOI: 10.1007/s00384-018-3036-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND "Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery. METHODS A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed. RESULTS Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact. CONCLUSIONS NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.
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20
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Laparoscopic versus open colectomy: the impact of frailty on outcomes. Updates Surg 2018; 71:89-96. [DOI: 10.1007/s13304-018-0531-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
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21
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Garfinkle R, Boutros M, Ghitulescu G, Vasilevsky CA, Charlebois P, Liberman S, Stein B, Feldman LS, Lee L. Clinical and Economic Impact of an Enhanced Recovery Pathway for Open and Laparoscopic Rectal Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:811-818. [PMID: 29451415 DOI: 10.1089/lap.2017.0677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The short-term benefits of laparoscopy for rectal surgery are equivocal. The objective of this study was to determine the clinical and economic impact of an enhanced recovery pathway (ERP) for laparoscopic and open rectal surgery. MATERIALS AND METHODS All patients who underwent elective rectal resection with primary anastomosis between January 2009 and March 2012 at two tertiary-care, university-affiliated institutions were identified. Patients who met inclusion criteria were divided into four groups, according to surgical approach (laparoscopic [lap] or open) and perioperative management (ERP or conventional care [CC]). Length of stay (LOS), postoperative complications, and hospital costs were compared. RESULTS A total of 381 patients were included in the analysis (201 open-CC, 34 lap-CC, 38 open-ERP, and 108 lap-ERP). Patients were mostly similar at baseline. ERPs significantly reduced median LOS after both open cases (open-CC 10 days versus open-ERP 7.5 days, P = .003) and laparoscopic cases (lap-CC 5 days versus lap-ERP 4.5 days, P = .046). ERPs also reduced variability in LOS compared with CC. There was no difference in postoperative complications with the use of ERPs (open-CC 51% versus open-ERP 50%, P = .419; lap-CC 32% versus lap-ERP 36%, P = .689). On multivariate analysis, both ERP (-3.6 days [95% confidence interval, CI -6.0 to -1.3]) and laparoscopy (-3.6 days [95% CI -5.9 to -1.0]) were independently associated with decreased LOS. Overall costs were only lower when lap-ERP was compared with open-CC (mean difference -2420 CAN$ [95% CI -5628 to -786]). CONCLUSIONS ERPs reduced LOS after rectal resections, and the combination of laparoscopy and ERPs significantly reduced overall costs compared to when neither strategy was used.
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Affiliation(s)
- Richard Garfinkle
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Marylise Boutros
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Gabriela Ghitulescu
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Carol-Ann Vasilevsky
- 2 Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital , Montreal, Quebec, Canada
| | - Patrick Charlebois
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Sender Liberman
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Barry Stein
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Liane S Feldman
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Lawrence Lee
- 1 Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre , Montreal, Quebec, Canada
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22
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Chen ST, Wu MC, Hsu TC, Yen DW, Chang CN, Hsu WT, Wang CC, Lee M, Liu SH, Lee CC. Comparison of outcome and cost among open, laparoscopic, and robotic surgical treatments for rectal cancer: A propensity score matched analysis of nationwide inpatient sample data. J Surg Oncol 2017; 117:497-505. [PMID: 29284067 DOI: 10.1002/jso.24867] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 09/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population-based studies evaluating outcomes of different approaches for rectal cancer are scarce. METHODS We conducted a retrospective cohort study using the Nationwide Inpatient Sample database between 2008 and 2012. We compared the outcomes and costs among rectal cancer patients undergoing robotic, laparoscopic, or open surgeries using propensity scores for adjusted and matched analysis. RESULTS We identified 194 957 rectal cancer patients. Over the 5-year period, the annual admission number decreased by 13.9%, the in-hospital mortality rate decreased by 32.2%, while the total hospitalization cost increased by 13.6%. Compared with laparoscopic surgery, robotic surgery had significantly lower length of stay (LOS) (OR 0.69, 95%CI 0.57-0.84), comparable wound complications (OR 1.08, 95%CI 0.70-1.65) and higher cost (OR 1.42, 95%CI 1.13-1.79), while open surgery had significantly longer LOS (OR 1.38, 95%CI 1.19-1.59), more wound complications (OR 1.49, 95%CI 1.08-1.79), and comparable cost (OR 0.92, 95%CI 0.79-1.07). There were no difference in in-hospital mortality among three approaches. CONCLUSIONS Laparoscopic surgery was associated with better outcomes than open surgery. Robotic surgery was associated with higher cost, but no advantage over laparoscopic surgery in terms of mortality and complications. Studies on cost-effectiveness of robotic surgery may be warranted.
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Affiliation(s)
- Szu-Ta Chen
- Division of Gastroenterology, Department of Pediatrics, National Taiwan University Hospital Yun-Lin Branch, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meng-Che Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Debra W Yen
- Department of Internal Medicine, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri
| | - Chia-Na Chang
- Department of Radiation Oncology, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Chun Wang
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | | | - Shing-Hwa Liu
- Graduate Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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23
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Mehta HB, Hughes BD, Sieloff E, Sura SO, Shan Y, Adhikari D, Senagore A. Outcomes of Laparoscopic Colectomy in Younger and Older Patients: An Analysis of Nationwide Readmission Database. J Laparoendosc Adv Surg Tech A 2017; 28:370-378. [PMID: 29237139 DOI: 10.1089/lap.2017.0521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Prior studies report safety and effectiveness of laparoscopic colectomy in older patients. The study aimed to examine the impact of laparoscopic colectomy on 30-day readmissions, discharge destination, hospital length of stay, and cost in younger (19-65 years) and older adults (>65 years). MATERIALS AND METHODS We used the nationwide readmission database from 2013 to study adults undergoing elective colectomy. The outcomes were 30-day readmissions, discharge destination for the index hospitalization (routine, skilled nursing facility [SNF]/intermediate care facility [ICF], home healthcare), length of stay, and cost. Multivariable analyses were conducted to determine the association of laparoscopic colectomy on outcome; logistic regression for 30-day readmission, multinomial logistic regression for discharge destination, and linear regression for length of stay and cost. An interaction between age and colectomy approach was included, and all models controlled gender, income, insurance status, All Patients Refined Diagnosis Related Groups (APR-DRG), Elixhauser comorbidities, hospital bed size, ownership, and teaching status. RESULTS Of 79,581 colectomies, 40.2% were laparoscopic. Laparoscopic colectomy was more frequent in younger patients (41.9% versus 38.5%, p < .0001). Regardless of age, patients undergoing laparoscopic colectomy were 20% less likely to be readmitted within 30 days (odds ratio [OR] 0.80, confidence interval [95% CI] 0.75-0.85). For postdischarge destination, laparoscopic colectomy offered higher benefits to younger patients (SNF/ICF: OR 0.42, 95% CI 0.36-0.49; home health: OR 0.32, 95% CI 0.30-0.35) than older patients (SNF/ICF: OR 0.50, 95% CI 0.47-0.54; home health: OR 0.59, 95% CI 0.55-0.62). Regardless of age, laparoscopic colectomy resulted in 1.46 days (p < .0001) shorter hospital stays compared to open colectomy. Laparoscopic colectomy had significantly lower cost compared to open approach, particularly in younger ($1,466) versus older ($632) patients. CONCLUSIONS Laparoscopic colectomy is superior to an open approach, with fewer 30-day readmissions, fewer discharges to SNF/ICF or home health, shorter hospital stays, and less overall cost; younger patients benefit more than older patients.
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Affiliation(s)
- Hemalkumar B Mehta
- 1 Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Byron D Hughes
- 1 Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Eric Sieloff
- 1 Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Sneha O Sura
- 2 School of Pharmacy, University of Houston , Houston, Texas
| | - Yong Shan
- 1 Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Deepak Adhikari
- 3 School of Public Health, Brown University , Providence, Rhode Island
| | - Anthony Senagore
- 1 Department of Surgery, University of Texas Medical Branch , Galveston, Texas
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24
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Damle A, Damle RN, Flahive JM, Schlussel AT, Davids JS, Sturrock PR, Maykel JA, Alavi K. Diffusion of technology: Trends in robotic-assisted colorectal surgery. Am J Surg 2017; 214:820-824. [DOI: 10.1016/j.amjsurg.2017.03.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/27/2017] [Accepted: 03/12/2017] [Indexed: 12/18/2022]
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25
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Growth in robotic-assisted procedures is from conversion of laparoscopic procedures and not from open surgeons’ conversion: a study of trends and costs. Surg Endosc 2017; 32:2106-2113. [DOI: 10.1007/s00464-017-5908-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/03/2017] [Indexed: 11/26/2022]
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26
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Healy MA, Regenbogen SE, Kanters AE, Suwanabol PA, Varban OA, Campbell DA, Dimick JB, Byrn JC. Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative. JAMA Surg 2017; 152:860-867. [PMID: 28614551 DOI: 10.1001/jamasurg.2017.1527] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons. Objective To assess rates of complications for MIC compared with OC among surgeons. Design, Setting, and Participants We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches. Main Outcomes and Measures Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC. Results Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC. Conclusions and Relevance Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.
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Affiliation(s)
- Mark A Healy
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Oliver A Varban
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Darrell A Campbell
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
| | - John C Byrn
- Department of Surgery, University of Michigan, Ann Arbor.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor.,Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor
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27
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Etter K, Davis B, Roy S, Kalsekar I, Yoo A. Economic Impact of Laparoscopic Conversion to Open in Left Colon Resections. JSLS 2017; 21:JSLS.2017.00036. [PMID: 28890650 PMCID: PMC5565639 DOI: 10.4293/jsls.2017.00036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Studies have shown economic and clinical advantages of laparoscopic left-colon resections. Laparoscopic conversion to open is an important surgical outcome. We estimated conversion incidence, identified risk factors, and measured the clinical and economic impact. METHODS In this retrospective study, we used the Premier Perspective database to analyze left-sided colectomies from 2009 to 2014. Operating room time (ORT), length of stay (LOS), total hospital cost (2014 U.S. dollars); along with incidence of in-hospital clinical outcomes (anastomotic leak surrogate [Leak], transfusion, and mortality) were evaluated. Multivariable models accounting for hospital clustering were used to identify conversion risk factors and analyze the effect of conversion on economic and clinical outcomes. RESULTS A total of 41,417 patients: 8,468 left hemicolectomy and 32,949 sigmoidectomy were identified. Lap-Conversion incidence was 13.3% (95% CI, 12.9-13.7). Adjusted mean LOS (±SE) days was significantly lower for the Lap-Successful group (4.9 compared with Lap-Conversion 6.8 and Open-Planned 7.0), but Lap-Conversion and Open-Planned had similar LOS. Adjusted mean cost was higher for Lap-Conversion $20,165 compared to Open-Planned $18,797; but this difference was smaller than the cost savings for Lap-Successful $16,206 ± $219. Open-Planned had lower odds of Leak compared to Lap-Conversion. Open-Planned and Lap-Conversion had similar odds of transfusion and mortality. Conversion risk factors included inflammatory bowel disease and left-hemicolectomy. Colorectal specialists were associated with 38% decreased odds of conversion. CONCLUSIONS Successful laparoscopic surgery was the most cost effective, with decreased LOS and odds of blood transfusion, leak surrogate, and mortality. Conversion was the most expensive and had increased odds of leak surrogate, but similar LOS compared to Open-Planned. The beneficial effect size of successful laparoscopic surgery was larger than the negative effect of conversion compared to Open-Planned.
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Affiliation(s)
- Katherine Etter
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Brad Davis
- CMC Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sanjoy Roy
- Global Health Economics and Market Access, Ethicon Inc., Somerville, New Jersey, USA
| | - Iftekhar Kalsekar
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | - Andrew Yoo
- Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
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Nayor J, Rotman SR, Chan WW, Goldberg JE, Saltzman JR. Endoscopic Localization of Colon Cancer Is Frequently Inaccurate. Dig Dis Sci 2017; 62:2120-2125. [PMID: 28466261 DOI: 10.1007/s10620-017-4591-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 04/25/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Colonoscopic location of a tumor can influence both the surgical procedure choice and overall treatment strategy. AIMS To determine the accuracy of colonoscopy in determining the location of colon cancer compared to surgical localization and to elucidate factors that predict discordant colon cancer localization. METHODS We conducted a retrospective cross-sectional study of colon cancers diagnosed on colonoscopy at two academic tertiary-care hospitals and two affiliated community hospitals from 2012 to 2014. Colon cancer location was obtained from the endoscopic and surgical pathology reports and characterized by colon segment. We collected data on patient demographics, tumor characteristics, endoscopic procedure characteristics, surgery planned, and surgery performed. Univariate analyses using Chi-squared test and multivariate analysis using forward stepwise logistic regression were performed to determine factors that predict discordant colon cancer localization. RESULTS There were 110 colon cancer cases identified during the study period. Inaccurate endoscopic colon cancer localization was found in 29% (32/110) of cases. These included 14 cases (12.7%) that were discordant by more than one colonic segment and three cases where the presurgical planned procedure was significantly changed at the time of surgery. On univariate analyses, right-sided colon lesions were associated with increased inaccuracy (43.8 vs 24.4%, p = 0.04). On multivariate analysis, right-sided colon lesions remained independently associated with inaccuracy (OR 1.74, 95% CI 1.03-2.93, p = 0.04). CONCLUSIONS Colon cancer location as determined by colonoscopy is often inaccurate, which can result in intraoperative changes to surgical management, particularly in the right colon.
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Affiliation(s)
- Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Stephen R Rotman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
| | - Joel E Goldberg
- Harvard Medical School, Boston, MA, USA.,Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
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29
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Greenawald L, Uribe J, Shariff F, Syed M, Shaikh M, Mann B, Pezzi C, Damewood R, Shewokis PA, Castellanos A, Lind DS. Construct validity of a novel, objective evaluation tool for the basics of open laparotomy training using a simulated model. Am J Surg 2017; 214:152-157. [DOI: 10.1016/j.amjsurg.2015.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 12/01/2015] [Accepted: 12/08/2015] [Indexed: 11/25/2022]
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30
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Lee MTG, Chiu CC, Wang CC, Chang CN, Lee SH, Lee M, Hsu TC, Lee CC. Trends and Outcomes of Surgical Treatment for Colorectal Cancer between 2004 and 2012- an Analysis using National Inpatient Database. Sci Rep 2017; 7:2006. [PMID: 28515452 PMCID: PMC5435696 DOI: 10.1038/s41598-017-02224-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 04/07/2017] [Indexed: 02/07/2023] Open
Abstract
Limited data are available for the epidemiology and outcome of colorectal cancer in relation to the three main surgical treatment modalities (open, laparoscopic and robotic). Using the US National Inpatient Sample database from 2004 to 2012, we identified 1,265,684 hospitalized colorectal cancer patients. Over the 9 year period, there was a 13.5% decrease in the number of hospital admissions and a 43.5% decrease in in-hospital mortality. Comparing the trend of surgical modalities, there was a 35.4% decrease in open surgeries, a 3.5 fold increase in laparoscopic surgeries, and a 41.3 fold increase in robotic surgeries. Nonetheless, in 2012, open surgery still remained the preferred surgical treatment modality (65.4%), followed by laparoscopic (31.2%) and robotic surgeries (3.4%). Laparoscopic and robotic surgeries were associated with lower in-hospital mortality, fewer complications, and shorter length of stays, which might be explained by the elective nature of surgery and earlier tumor grades. After excluding patients with advanced tumor grades, laparoscopic surgery was still associated with better outcomes and lower costs than open surgery. On the contrary, robotic surgery was associated with the highest costs, without substantial outcome benefits over laparoscopic surgery. More studies are required to clarify the cost-effectiveness of robotic surgery.
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Affiliation(s)
- Meng-Tse Gabriel Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chia-Chun Wang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chia-Na Chang
- Department of Radiation Oncology, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan
| | | | | | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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31
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Cerdán Santacruz C, Frasson M, Flor-Lorente B, Ramos Rodríguez JL, Trallero Anoro M, Millán Scheiding M, Maseda Díaz O, Dujovne Lindenbaum P, Monzón Abad A, García-Granero Ximenez E. Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study. Surg Endosc 2017; 31:5032-5042. [PMID: 28455773 DOI: 10.1007/s00464-017-5548-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. METHODS This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. RESULTS 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). CONCLUSIONS In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.
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Affiliation(s)
- Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - Marta Trallero Anoro
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | | | | | | | - Eduardo García-Granero Ximenez
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
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32
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Colon Cancer Surgery: A Retrospective Study Based on a Large Administrative Database. Surg Laparosc Endosc Percutan Tech 2016; 26:e126-e131. [DOI: 10.1097/sle.0000000000000350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Hotouras A, Ribas Y, Zakeri SA, Nunes QM, Murphy J, Bhan C, Wexner SD. The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review. Colorectal Dis 2016; 18:O337-O366. [PMID: 27254110 DOI: 10.1111/codi.13406] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
Abstract
AIM The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection. METHOD A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined. RESULTS Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time. CONCLUSION Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.
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Affiliation(s)
- A Hotouras
- National Centre for Bowel Research and Surgical Innovation, London, UK. .,Department of Surgery, Whittington Hospital NHS Trust, London, UK.
| | - Y Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Terrassa (Barcelona), Spain
| | - S A Zakeri
- Department of Surgery, Whittington Hospital NHS Trust, London, UK
| | - Q M Nunes
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - J Murphy
- Academic Surgical Unit, Imperial College London, London, UK
| | - C Bhan
- Department of Surgery, Whittington Hospital NHS Trust, London, UK
| | - S D Wexner
- Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Abstract
Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.
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Affiliation(s)
- Matthew Whealon
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Vinci
- Department of Surgery, University of California, Irvine, Orange, California
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, Orange, California
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35
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Abstract
BACKGROUND Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections. OBJECTIVE Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies. DESIGN This was a retrospective study using the Premier Perspective database. SETTINGS Included were patient hospitalizations nationwide from January 2006 to December 2013. PATIENTS A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study. MAIN OUTCOME MEASURES Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery). RESULTS Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63-0.82)), ertapenem (OR = 0.65 (95% CI, 0.58-0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49-0.64)), and "other" (OR = 0.81 (95% CI, 0.73-0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings. LIMITATIONS The study was limited by its lack of detailed clinical information in the billing data set used. CONCLUSIONS In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.
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Abstract
BACKGROUND The rates of laparoscopic colectomy for colon cancer have steadily increased since its inception. Laparoscopic colectomy currently accounts for a third of colectomy procedures in the United States, but little is known regarding the spatial pattern of the utilization of laparoscopy for colon cancer. OBJECTIVE This study evaluated the utilization of laparoscopy for colon cancer at the neighborhood level in Ontario. DESIGN Retrospective analysis of prospectively collected data was performed. SETTING This study was conducted at all hospitals in the province of Ontario. PATIENTS This population-based study included all patients aged ≥18 who received an elective colectomy for colon cancer from April 2008 until March 2012 in the province of Ontario. MAIN OUTCOME MEASURES The primary outcome measure was the neighborhood rates of laparoscopy. RESULTS Overall, 9,969 patients underwent surgery, and the cluster analysis identified 74 cold-spot neighborhoods, representing 1.8 million people, or 14% of the population. In the multivariate analysis, patients from rural neighborhoods were less than half as likely to receive laparoscopy, OR 0.44 (95% CI, 0.24-0.84; p = 0.012). Additionally, having a minimally invasive surgery fellowship training facility within the same administrative health region as the neighborhood made it more than 23 times as likely to be a hot spot, OR 25.88 (95% CI, 12.15-55.11; p < 0.001). Neighborhood socioeconomic status was not associated with variation in the utilization of laparoscopy. LIMITATIONS Patient case mix could affect laparoscopy use. CONCLUSION AND RELEVANCE This study identified an unequal utilization of laparoscopy for colon cancer within Ontario with rural neighborhoods experiencing low rates of laparoscopic colectomy, whereas neighborhoods in the same administrative region as minimally invasive surgery training centers experienced increased utilization. Further study into the causes of this variation in resource allocation is needed to identify ways to improve more efficient spread of knowledge and technical skills advancement.
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Does Conversion in Laparoscopic Colectomy Portend an Inferior Oncologic Outcome? Results from 104,400 Patients. J Gastrointest Surg 2016; 20:1042-8. [PMID: 26768006 PMCID: PMC5142516 DOI: 10.1007/s11605-016-3073-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/02/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited data exist regarding the effect of conversion from laparoscopic to open colectomy on perioperative and oncologic outcomes in colon cancer. STUDY DESIGN The National Cancer Data Base was used to identify patients who underwent colectomy for non-metastatic colon cancer (2010-2012). Patients were stratified into three groups: laparoscopic/robotic-assisted colectomy (MIC), converted colectomy (CC), and open colectomy (OC). Multivariable modeling was applied to compare outcomes from CC and MIC to OC while adjusting for patient, clinical, and tumor characteristics. RESULTS Of 104,400 patients, 40,328 (38.6 %) underwent MIC, 57,928 (55.5 %) OC, and 6144 (5.9 %) CC. After adjustment, the rate of positive surgical margins was not significantly different between CC and OC (p = 0.44). However, with adjustment, CC versus OC was associated with shorter hospital length of stay (4 % decrease, 95 % CI 2-5 %, p < 0.0001) and lower odds of 30-day mortality (OR 0.77, 95 % CI 0.64-0.94, p = 0.0112). Adjusted overall survival was similar between CC and OC (p = 0.34). CONCLUSIONS Conversion from laparoscopic to open colectomy was not associated with compromised oncologic outcomes, while maintaining improved short-term outcomes despite being attempted in only 45 % of patients. This data suggests that utilization of laparoscopic colectomy should be attempted for patients with colon cancer.
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Lotti M, Capponi MG, Campanati L, Bertoli P, Palamara F, Coccolini F, Ansaloni L. Laparoscopic right colectomy: Miles away or just around the corner? J Minim Access Surg 2016; 12:41-6. [PMID: 26917918 PMCID: PMC4746974 DOI: 10.4103/0972-9941.158960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND: Despite the drive toward centralization of surgery in high-volume centers, the majority of colectomies are still performed by low- or medium-volume surgeons. MATERIALS AND METHODS: A modification of the technique of laparoscopic right colectomy (LRC) originally described by Young-Fadok and Nelson was developed. The key points of that technique were maintained, but a different port-site layout and a counterclockwise approach were adopted, to warrant better trocar triangulation, to reduce the need of right colon manipulation and to avoid dissection along false planes. This modified technique was applied in 82 patients by 16 surgeons with no previous experience in LRC. RESULTS: Average operative time was 125 ± 35 min. Conversion occurred in 10 cases (12.2%). Grade III postoperative complications occurred in 3 patients (3.6%). No postoperative mortality was observed. Average number of lymph nodes retrieved was 19 ± 6. Average length of stay was 7 ± 4 days. CONCLUSION: Providing low-volume surgeons with simplified and easy-to-learn surgical techniques could improve outcomes and lead to an increased use of laparoscopy.
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Affiliation(s)
- Marco Lotti
- Department of General Surgery 1, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Luca Campanati
- Advanced Surgical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paolo Bertoli
- Advanced Surgical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fabrizio Palamara
- Advanced Surgical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- Advanced Surgical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Ansaloni
- Advanced Surgical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Zafar SN, Ahaghotu CA, Libuit L, Ortega G, Coleman PW, Cornwell EE, Tran DD, Fullum TM. Ureteral injury after laparoscopic versus open colectomy. JSLS 2016; 18:JSLS-D-14-00158. [PMID: 25392666 PMCID: PMC4208902 DOI: 10.4293/jsls.2014.00158] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: Ureteral injury is an infrequent but potentially lethal complication of colectomy. We aimed to determine the incidence of intraoperative ureteral injury after laparoscopic and open colectomy and to determine the independent morbidity and mortality rates associated with ureteral injury. Methods: We analyzed data from the National Surgical Quality Improvement Program for the years 2005–2010. All patients undergoing colectomy for benign, neoplastic, or inflammatory conditions were selected. Patients undergoing laparoscopic colectomy versus open colectomy were matched on disease severity and clinical and demographic characteristics. Multivariate logistic regression analyses and coarsened exact matching were used to determine the independent difference in the incidence of ureteral injury between the 2 groups. Multivariate models were also used to determine the independent association between postoperative complications associated with ureteral injury. Results: Of a total of 94 526 colectomies, 33 092 (35%) were completed laparoscopically. Ureteral injury occurred in a total of 585 patients (0.6%). The crude incidence in the open group was higher than that in the laparoscopic group (0.66% versus 0.53%, P = .016). CEM produced 14 630 matching pairs. Matched analysis showed the likelihood of ureteral injury after laparoscopic colectomy to be 30% less than after open colectomy (odds ratio, 0.70; 95% confidence interval, 0.51–0.96). Patients with ureteral injury were independently more likely to have septic complications and have longer lengths of hospital stay than those without ureteral injury. Conclusion: Laparoscopic colectomy is associated with a lower incidence of intraoperative ureteral injury when compared with open procedures. Ureteral injury leads to significant postoperative morbidity even if identified and repaired during the colectomy.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Chiledum A Ahaghotu
- Division of Urology, Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Laura Libuit
- School of Medicine, Howard University, Washington, DC, USA
| | - Gezzer Ortega
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Pamela W Coleman
- Division of Urology, Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Daniel D Tran
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Terrence M Fullum
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Howard University Hospital, Washington, DC, USA
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Abstract
The adoption of laparoscopic colorectal surgery has been a slow but steady progress. The first adopters rapidly expanded the application of the technology to all colorectal pathology. Issues related to extraction and port site recurrence of cancer delayed widespread adoption until incontrovertible data from well-powered prospective randomized studies confirmed equipoise with open surgery. Since that time, the data has consistently demonstrated patient-care benefits related to reductions in both short- and long-term complications historically associated with open colectomy. The potential for further improvement related to single-port access, robotic assistance, and natural orifice access for both the surgery and/or extraction will await the test of time. However, it is clear now that laparoscopic colorectal surgery is the new standard of care and a key enabler of enhanced recovery programs.
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Affiliation(s)
- Anthony J Senagore
- Department of Surgery, Case Western Reserve University, School of Medicine, Cleveland, Ohio
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Celentano V. Need for simulation in laparoscopic colorectal surgery training. World J Gastrointest Surg 2015; 7:185-189. [PMID: 26425266 PMCID: PMC4582235 DOI: 10.4240/wjgs.v7.i9.185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 06/07/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.
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Kotake K, Kobayashi H, Asano M, Ozawa H, Sugihara K. Influence of extent of lymph node dissection on survival for patients with pT2 colon cancer. Int J Colorectal Dis 2015; 30:813-20. [PMID: 25808013 DOI: 10.1007/s00384-015-2194-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal extent of lymph node dissection for early-stage colon cancer (CC) remains undefined. This study assessed the influence of the extent of lymph node dissection on overall survival (OS) in patients with pT2 CC. METHODS We retrospectively examined data from the multi-institutional registry system of the Japanese Society for Cancer of the Colon and Rectum and used a propensity score matching method to balance potential confounders of lymph node dissection. We extracted 463 matched pairs from 1433 patients who underwent major resections for pT2 CC between 1995 and 2004. RESULTS Lymph node metastasis was found in 301 (21.0%) of 1433 patients with pT2 CC. In this cohort, significant independent risk factors for lymph node metastasis were lymphatic invasion and venous invasion. Patients who underwent D3 or D2 lymph node dissection did not significantly differ in OS, either among the propensity score-matched cohort (estimated hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.536-1.346, P = 0.484) or in the cohort as a whole (HR 0.720, 95% CI 0.492-1.052, P = 0.089). CONCLUSIONS For patients with pT2 CC, D3 lymph node dissection did not add to OS. D2 lymph node dissection may be adequate for pT2 CC.
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Affiliation(s)
- Kenjiro Kotake
- Department of Colorectal Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan,
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Abstract
Surgical management of inflammatory bowel disease is a challenging endeavor given infectious and inflammatory complications, such as fistula, and abscess, complex often postoperative anatomy, including adhesive disease from previous open operations. Patients with Crohn's disease and ulcerative colitis also bring to the table the burden of their chronic illness with anemia, malnutrition, and immunosuppression, all common and contributing independently as risk factors for increased surgical morbidity in this high-risk population. However, to reduce the physical trauma of surgery, technologic advances and worldwide experience with minimally invasive surgery have allowed laparoscopic management of patients to become standard of care, with significant short- and long-term patient benefits compared with the open approach. In this review, we will describe the current state-of the-art for minimally invasive surgery for inflammatory bowel disease and the caveats inherent with this practice in this complex patient population. Also, we will review the applicability of current and future trends in minimally invasive surgical technique, such as laparoscopic "incisionless," single-incision laparoscopic surgery (SILS), robotic-assisted, and other techniques for the patient with inflammatory bowel disease. There can be no doubt that minimally invasive surgery has been proven to decrease the short- and long-term burden of surgery of these chronic illnesses and represents high-value care for both patient and society.
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Gruber K, Soliman AS, Schmid K, Rettig B, Ryan J, Watanabe-Galloway S. Disparities in the Utilization of Laparoscopic Surgery for Colon Cancer in Rural Nebraska: A Call for Placement and Training of Rural General Surgeons. J Rural Health 2015; 31:392-400. [PMID: 25951881 DOI: 10.1111/jrh.12120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Advances in medical technology are changing surgical standards for colon cancer treatment. The laparoscopic colectomy is equivalent to the standard open colectomy while providing additional benefits. It is currently unknown what factors influence utilization of laparoscopic surgery in rural areas and if treatment disparities exist. The objectives of this study were to examine demographic and clinical characteristics associated with receiving laparoscopic colectomy and to examine the differences between rural and urban patients who received either procedure. METHODS This study utilized a linked data set of Nebraska Cancer Registry and hospital discharge data on colon cancer patients diagnosed and treated in the entire state of Nebraska from 2008 to 2011 (N = 1,062). Multiple logistic regression analysis was performed to identify predictors of receiving the laparoscopic treatment. RESULTS Rural colon cancer patients were 40% less likely to receive laparoscopic colectomy compared to urban patients. Independent predictors of receiving laparoscopic colectomy were younger age (<60), urban residence, ≥3 comorbidities, elective admission, smaller tumor size, and early stage at diagnosis. Additionally, rural patients varied demographically compared to urban patients. CONCLUSIONS Laparoscopic surgery is becoming the new standard of treatment for colon cancer and important disparities exist for rural cancer patients in accessing the specialized treatment. As cancer treatment becomes more specialized, the importance of training and placement of general surgeons in rural communities must be a priority for health care planning and professional training institutions.
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Affiliation(s)
- Kelli Gruber
- Department of Epidemiology, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska
| | - Amr S Soliman
- Department of Epidemiology, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska
| | - Kendra Schmid
- Department of Biostatistics, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska
| | - Bryan Rettig
- Nebraska Department of Health and Human Services, Lincoln, Nebraska
| | - June Ryan
- Nebraska Cancer Coalition, Omaha, Nebraska.,Nebraska Comprehensive Cancer Control Program, Nebraska Department of Health and Human Services, Lincoln, Nebraska
| | - Shinobu Watanabe-Galloway
- Department of Epidemiology, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska
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How surgical technology translates into practice: the model of laparoscopic liver resections performed in France. Ann Surg 2015; 260:916-21; discussion 921-2. [PMID: 25243552 DOI: 10.1097/sla.0000000000000950] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Analyze, at a national level, the adoption and practice of laparoscopic liver resections (LAP), compared to open resections (OPEN). BACKGROUND LAP initiated 20 years ago, has been described for all hepatectomies, and is considered as the reference technique for some resections. There are, however, no data on its adoption outside selected specialty centers. METHODS French Healthcare databases were screened to identify all patients who underwent an elective LAP or OPEN between 2007 and 2012. Patients' demographics, associated conditions, indication for surgery, hepatectomy performed, and hospital type and hepatectomy caseload were retrieved. Patients who had possible overcoding of biopsies as wedge resections were identified to select REAL resections. Time trend analyses were performed using a piecewise linear regression and the average annual percent change (AAPC) calculated. RESULTS There were 7881 (17.8%) LAP and 36,359 (82.2%) OPEN performed in an average of 483 hospitals. Of these, biopsies accounted for 29.9% of the LAP (7.3% of the OPEN, P<0.0001) and the incidence of LAP biopsies increased after 2009. The AAPC of the incidence of real LAP increased more than that of real OPEN (7.0% vs 1.3%) but most were minor resections (61.1% vs 28.9% for OPEN, P<0.0001), only 15% of patients were operated by LAP and intermediate (or major) resections were performed in 19.5% (or 4.8%) of hospitals performing liver resections. The proportion of resections performed by LAP was inversely related to annual caseload. The overall incidence of resections performed for benign conditions did not increase. CONCLUSIONS LAP is not developing, has not been adopted for intermediate/major resections, does not result in overuse for benign indications and some of the 2009 -consensus statements are not applied.
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Luglio G, De Palma GD, Tarquini R, Giglio MC, Sollazzo V, Esposito E, Spadarella E, Peltrini R, Liccardo F, Bucci L. Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study. Ann Med Surg (Lond) 2015; 4:89-94. [PMID: 25859386 PMCID: PMC4388911 DOI: 10.1016/j.amsu.2015.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023] Open
Abstract
Background Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol. Methods The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. Results Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. Conclusion Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon. Benefits from laparoscopic colorectal surgery have been widely demonstrated. A steep learning curve is considered the main limitation to its adoption. We present short-term outcomes in a learning curve prospective series. A modular, stepwise approach leads to excellent results. Even trainees can safely learn both laparoscopic and open surgery, when strictly supervised.
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Affiliation(s)
- Gaetano Luglio
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy ; Center of Excellence for Technical Innovation in Surgery (CEITC), Italy
| | - Rachele Tarquini
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Emanuela Esposito
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Emanuela Spadarella
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Roberto Peltrini
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Filomena Liccardo
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
| | - Luigi Bucci
- Department of Clinical Medicine and Surgery, School of Medicine-Surgical Coloproctology Unit, University of Naples Federico II, Naples, Italy
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Zhuang CL, Huang DD, Chen FF, Zhou CJ, Zheng BS, Chen BC, Shen X, Yu Z. Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2014; 29:2091-100. [PMID: 25414064 DOI: 10.1007/s00464-014-3922-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) -1.92 days; 95 % confidence interval (CI) -2.61--1.23 days; P < 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66-0.94; P = 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality. CONCLUSIONS Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.
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Affiliation(s)
- Cheng-Le Zhuang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical University, 2 Fuxue Lane, Wenzhou, 325000, Zhejiang, China
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Araujo SEA, Seid VE, Bertoncini AB, Horcel LA, Nahas SC, Cecconello I. Single-session baseline virtual reality simulator scores predict technical performance for laparoscopic colectomy: a study in the swine model. JOURNAL OF SURGICAL EDUCATION 2014; 71:883-891. [PMID: 24994032 DOI: 10.1016/j.jsurg.2014.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 05/01/2014] [Accepted: 05/29/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Virtual reality (VR) simulation helps reducing the learning curve of laparoscopic colectomy. Moreover, it may be used to ascertain surgeons' pretraining skills. It was aimed to establish predictive validity of specific parameters gathered during VR simulation training on sigmoid colectomy and whether simulator parameters correlate with technical performance during the same operation in a swine model. DESIGN Surgeons novice to laparoscopic colectomy underwent a single VR simulation session on sigmoid colectomy. Next, all participants performed a laparoscopic sigmoidectomy in the swine. Operations were recorded. Performance evaluation was conducted by 2 board-certified colorectal surgeons blinded to surgeons' simulator scores using an instrument specific to laparoscopic colectomy. For each participant, a mean score of specific skills was calculated. Linear regression analysis was used to identify simulator parameters that were best related to the score. The stepwise method was used to select parameters. The magnitude of the regression model was measured by the coefficient of determination (R(2)) value. SETTING The University of Sao Paulo Medical Center is a high-volume, public practice, university-affiliated hospital. PARTICIPANTS A total of 14 first-year residents in digestive tract surgery were included. RESULTS Analysis of variance demonstrated that the regression model was significant (p = 0.0001), and an association between simulation scores and specific skills was confirmed. The R(2) value was 99%. The VR simulator parameters that strongly correlated with specific skills during laparoscopic colectomy in the swine were safe use of electrosurgery/energy device and safety of medial-to-lateral dissection. CONCLUSIONS A single VR simulation session for novice surgeons in the sigmoid colectomy module generates baseline scores that highly correlated with performance of specific skills during a laparoscopic colectomy in the swine. This information may be useful in an attempt to tailor VR simulator practice according to a surgeon's needs.
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Affiliation(s)
- Sergio Eduardo Alonso Araujo
- Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil; Division of Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil.
| | - Victor E Seid
- Division of Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil
| | - Alexandre B Bertoncini
- Division of Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil
| | - Lucas A Horcel
- Division of Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil
| | - Sergio C Nahas
- Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil; Division of Colorectal Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil; Division of Digestive Surgery, University of Sao Paulo Medical Center, Sao Paulo, Brazil
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Ejaz A, Sachs T, He J, Spolverato G, Hirose K, Ahuja N, Wolfgang CL, Makary MA, Weiss M, Pawlik TM. A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample. Surgery 2014; 156:538-47. [PMID: 25017135 DOI: 10.1016/j.surg.2014.03.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. METHODS We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. RESULTS A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). CONCLUSION During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.
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Affiliation(s)
- Aslam Ejaz
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Teviah Sachs
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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