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Gu YJ, Chen LM, Gu ME, Xu HX, Li J, Wu LY. Body mass index-based predictions and personalized clinical strategies for colorectal cancer in the context of PPPM. EPMA J 2022; 13:615-632. [PMID: 36505896 PMCID: PMC9727065 DOI: 10.1007/s13167-022-00306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
Currently colorectal cancer (CRC) is the third most prevalent cancer worldwide. Body mass index (BMI) is frequently used in CRC screening and risk assessment to quantitatively evaluate weight. However, the impact of BMI on clinical strategies for CRC has received little attention. Within the framework of the predictive, preventive, and personalized medicine (3PM/PPPM), we hypothesized that BMI stratification would affect the primary, secondary, and tertiary care options for CRC and we conducted a critical evidence-based review. BMI dynamically influences CRC outcomes, which helps avoiding adverse treatment effects. The outcome of surgical and radiation treatment is adversely affected by overweight (BMI ≥ 30) or underweight (BMI < 20). A number of interventions, such as enhanced recovery after surgery and robotic surgery, can be applied to CRC at all levels of BMI. BMI-controlling modalities such as exercise, diet control, nutritional therapy, and medications may be potentially beneficial for patients with CRC. Patients with overweight are advised to lose weight through diet, medication, and physical activity while patients suffering of underweight require more focus on nutrition. BMI assists patients with CRC in better managing their weight, which decreases the incidence of adverse prognostic events during treatment. BMI is accessible, noninvasive, and highly predictive of clinical outcomes in CRC. The cost-benefit of the PPPM paradigm in developing countries can be advanced, and the clinical benefit for patients can be improved with the promotion of BMI-based clinical strategy models for CRC.
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Affiliation(s)
- Yun-Jia Gu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China ,grid.412540.60000 0001 2372 7462Shanghai Qigong Research Institute, Shanghai University of Traditional Chinese Medicine, No. 650 South Wanping Road, Shanghai, 200030 China
| | - Li-Ming Chen
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Mu-En Gu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Hong-Xiao Xu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Jing Li
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
| | - Lu-Yi Wu
- grid.412540.60000 0001 2372 7462Yueyang Hospital of Integrated Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110 Ganhe Road, Shanghai, 200437 China
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Verma A, Kumar S. Laparoscopy in Colonic Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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3
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Butterworth JW, Boshier PR, Mavroveli S, Van Lanschot JB, Sasako M, Reynolds JV, Hanna GB. Challenges to quality assurance of surgical interventions in clinical oncology trials: A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:748-756. [PMID: 33059943 DOI: 10.1016/j.ejso.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/22/2020] [Accepted: 10/02/2020] [Indexed: 12/01/2022]
Abstract
Where surgery forms the primary curative modality in surgical oncology trials the quality of this intervention has the potential to directly influence outcomes. Many trials however lack a robust framework to ensure surgical quality. We aim to report existing published challenges to quality assurance of surgical interventions within oncological trials. A systematic on-line literature search of Embase and Medline identified 34 relevant studies, including 19 RCTs, 11 further analyses of the primary RCTs, and 4 trial protocols. Inclusion criteria: oncological RCTs with a surgical intervention and/or associated publications relevant to the research question; 'Challenges to quality assurance of surgery in clinical oncology trials'. Selected articles were assessed by two reviewers to identify reported challenges to quality assurance of surgical intervention within these trials. Reported challenges to surgical quality could be classified as those affecting credentialing, standardisation and monitoring of surgical interventions. Constraints of using case volume for credentialing surgeons; inter-centre variation in the definition and execution of interventions; insufficient training, and monitoring of surgical quality, were the most commonly encountered challenges within each of these three domains. Findings confirmed an inadequacy in the implementation and reporting of effective surgical quality assurance measures. The surgical community should enable implementation of agreed upon mitigating strategies to overcome challenges to surgical quality in oncology trials.
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Affiliation(s)
| | - Piers R Boshier
- Department of Surgery and Cancer, Imperial College London, UK
| | | | | | | | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital, Trinity College Dublin, Ireland
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, UK
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The ALCCaS Trial: A Randomized Controlled Trial Comparing Quality of Life Following Laparoscopic Versus Open Colectomy for Colon Cancer. Dis Colon Rectum 2018; 61:1156-1162. [PMID: 30192324 DOI: 10.1097/dcr.0000000000001165] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study reports the quality-of-life assessment of the ALCCaS trial. The ALCCaS trial compared laparoscopic and open resection for colon cancer. It reported equivalence of survival at 5 years. Quality of life was measured as a secondary outcome. OBJECTIVE This study aimed to report on the quality of life data of the ALCCaS Trial. DESIGN This study reports a randomized controlled trial comparing laparoscopic with open colonic resection. SETTINGS The study was conducted in Australasia. PATIENTS Patients with a single adenocarcinoma of the right, left, or sigmoid colon, presenting for elective treatment, were eligible for randomization. INTERVENTIONS Open and laparoscopic colonic resections were performed. MAIN OUTCOME MEASURES Patient symptoms and quality of life were measured using the Symptoms Distress Scale, the Quality of Life Index, and the Global Quality of Life Score preoperatively, and at 2 days, 2 weeks, and 2 months postoperatively. RESULTS Of the 592 patients enrolled in ALCCaS, 425 completed at least 1 quality-of-life measure at 4 time points (71.8% of cohort). Those who received the laparoscopic intervention had better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01), Quality of Life Index (p < 0.01), and Global Quality of Life (p < 0.01). In intention-to-treat analyses, those assigned to laparoscopic surgery had a better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01) and Quality of Life Index (p < 0.01), whereas Global Quality of Life was not significant (p = 0.056). The subscales better for laparoscopic resection at all 3 postoperative time points were appetite, insomnia, pain, fatigue, bowel, daily living, and health (p < 0.05). LIMITATIONS The primary limitation was the different response rates for the 3 quality-of-life measures. CONCLUSIONS There was a short-term gain in quality of life maintained at 2 months postsurgery for those who received laparoscopic relative to open colonic resection. See Video Abstract at http://links.lww.com/DCR/A691.
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Bell S, Kong JC, Wale R, Staples M, Oliva K, Wilkins S, Mc Murrick P, Warrier SK. The effect of increasing body mass index on laparoscopic surgery for colon and rectal cancer. Colorectal Dis 2018; 20:778-788. [PMID: 29577556 DOI: 10.1111/codi.14107] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/05/2018] [Indexed: 12/12/2022]
Abstract
AIM Obesity is common in Western countries and its prevalence is increasing. Colorectal cancer is common, and surgery for colorectal cancer is technically more challenging in obese patients. Laparoscopic surgery for colon cancer has been shown to be oncologically equivalent, with improved short- term outcomes. Laparoscopic surgery for rectal cancer has proven technically challenging, and recent results have raised concerns about oncological equivalence. Our aim was to evaluate the effect of body mass index (BMI) on the clinical and oncological outcomes of surgery for colorectal cancer, including the rate at which laparoscopic surgery is attempted and the rate at which laparoscopic surgery is converted to open surgery. METHOD A retrospective analysis of prospectively collected data from two tertiary institutions was performed. Data were obtained from the Cabrini Monash University colorectal neoplasia database for patients having surgical resection for colon and rectal cancers between 1 January 2010 and 30 June 2015. Surgical and medical complications, tumour recurrence and overall survival and laparoscopic surgery and conversion rates were investigated. RESULTS This large case series of 1464 patients undergoing elective surgery for colorectal cancer has demonstrated that an elevated BMI is associated with a lower likelihood of attempting laparoscopic surgery and a higher conversion rate to open surgery when laparoscopy is attempted. Conversion was 1.9 times more likely in obese patients with colon cancer and 4.1 times more likely in obese patients with rectal cancer. The critical BMI for colon cancer patients was > 35 kg/m2 , and for rectal cancer patients > 30 kg/m2 . Obesity is also associated with increased rates of surgical complications, including anastomotic leakage and wound complications. Pathological parameters, tumour recurrence and survival were not affected by elevated BMI. CONCLUSION In the surgical management of colorectal cancer, obesity is associated with a lower likelihood of laparoscopic surgery being attempted, a higher likelihood of conversion to open surgery when laparoscopic surgery is attempted, and a higher rate of surgical complications.
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Affiliation(s)
- S Bell
- Department of Colorectal Surgery, Alfred Health, Prahran, Victoria, Australia.,Department of Surgery, Cabrini Hospital, Cabrini Monash University, Malvern, Australia
| | - J C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - R Wale
- Department of Colorectal Surgery, Alfred Health, Prahran, Victoria, Australia
| | - M Staples
- Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Australia
| | - K Oliva
- Department of Surgery, Cabrini Hospital, Cabrini Monash University, Malvern, Australia
| | - S Wilkins
- Department of Surgery, Cabrini Hospital, Cabrini Monash University, Malvern, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - P Mc Murrick
- Department of Surgery, Cabrini Hospital, Cabrini Monash University, Malvern, Australia
| | - S K Warrier
- Department of Colorectal Surgery, Alfred Health, Prahran, Victoria, Australia
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Meagher AP, Yang S, Li S. Is it right to ignore learning-curve patients? Laparoscopic colorectal trials. ANZ J Surg 2017. [PMID: 28640984 DOI: 10.1111/ans.14070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Increasingly complex, technically demanding surgical procedures utilizing emerging technologies have developed over recent decades and are recognized as having long 'learning curves'. This raises significant new issues. Ethically and scientifically, the outcome of a patient in the learning curve is as important as the outcome of a patient outside the learning curve. The aim of this study is to highlight just one aspect of our approach to learning-curve patients that should change. METHODS The protocols of multicentre, prospective, randomized trials of patients undergoing either traditional open or laparoscopic surgery for colorectal cancer were reviewed. The number of patients excluded from the published trial results because they were in surgeons' learning curves was calculated. The seven editorials accompanying these publications were also examined for any mention of these patients. RESULTS The eight studies identified had similar designs. All patients in the surgeons' laparoscopic learning curves, which were often several years long, were excluded from the actual trials. The total number of patients included in the trial publications was 5680. The number of patients excluded because they were in the surgeons' laparoscopic learning curves was >10 605. In none of the studies or accompanying editorials is there any mention of the total number of patients in the surgeons' learning curves, these patients' outcomes or how inclusion of their outcomes might have affected the overall results. CONCLUSION Learning curves are inescapable in modern medicine. Our recognition of patients in these curves should evolve, with more data about them included in trial publications.
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Affiliation(s)
- Alan P Meagher
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Shi Yang
- Department of Colorectal Surgery, Tianjin Union Medical Centre, Tianjin, China
| | - Shuyuan Li
- Department of Colorectal Surgery, Tianjin Union Medical Centre, Tianjin, China
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Toh JWT, Lim R, Keshava A, Rickard MJFX. The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review. Colorectal Dis 2016; 18:1133-1141. [PMID: 27440227 DOI: 10.1111/codi.13464] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/08/2016] [Indexed: 12/28/2022]
Abstract
AIM To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication. METHOD Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis. RESULTS The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%). CONCLUSION Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.
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Affiliation(s)
- J W T Toh
- Concord Institute of Academic Surgery, Department of Colorectal Surgery, Concord, New South Wales, Australia
| | - R Lim
- Bankstown Hospital, Bankstown, New South Wales, Australia
| | - A Keshava
- Concord Institute of Academic Surgery, Department of Colorectal Surgery, Concord, New South Wales, Australia
| | - M J F X Rickard
- Concord Institute of Academic Surgery, Department of Colorectal Surgery, Concord, New South Wales, Australia
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O'Mahoney PRA, Trencheva K, Zhuo C, Shukla PJ, Lee SW, Sonoda T, Milsom JW. Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study. J Laparoendosc Adv Surg Tech A 2016; 25:737-43. [PMID: 26375772 DOI: 10.1089/lap.2014.0603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy. MATERIALS AND METHODS A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons. RESULTS Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels. CONCLUSIONS Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.
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Affiliation(s)
- Paul R A O'Mahoney
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
| | - Koiana Trencheva
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
| | - Changhua Zhuo
- 2 Department of Surgical Oncology, Fujian Provincial Cancer Hospital, Teaching Hospital of Fujian Medical University , Fuzhou, People's Republic of China
| | - Parul J Shukla
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
| | - Sang W Lee
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
| | - Toyooki Sonoda
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
| | - Jeffrey W Milsom
- 1 Section of Colon and Rectal Surgery, Department of Surgery, NewYork Presbyterian Hospital, Weill Cornell Medical College , New York, New York
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Methods of quality assurance in multicenter trials in laparoscopic colorectal surgery: a systematic review. Ann Surg 2015; 260:220-9. [PMID: 24743623 DOI: 10.1097/sla.0000000000000660] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess the risk of bias in multicenter randomized controlled trials (RCTs) investigating laparoscopic colorectal cancer surgery and review the use of quality assurance mechanisms to reduce performance bias. BACKGROUND RCTs represent the criterion standard comparison for health care interventions. For trials investigating interventional techniques, performance bias can arise through variation in delivery of the intervention. METHODS A comprehensive systematic review was undertaken using MEDLINE and EMBASE databases to identify all large RCTs investigating laparoscopic colorectal cancer surgery. Risk of performance bias was evaluated through assessment of publications and protocols to identify methods used for quality assurance of surgical technique. In addition, the Cochrane Collaboration's "risk of bias" tool was used to evaluate other potential sources of bias. RESULTS The literature search identified 48 publications, reporting upon 8 individual RCTs. All studies used mechanisms for quality assurance of laparoscopic colorectal surgery. Methods employed included credentialing of surgeons or units through assessment of experience and expertise, standardization of surgical technique, and monitoring. None report the use of structure objective assessment tools for accrediting expertise. All 8 were assessed as low risk of bias using the Cochrane tool. A framework is proposed for use as a model for quality assurance in future surgical trials. CONCLUSIONS Consideration of risk of performance bias is important when appraising trials investigating an interventional technique. Laparoscopic colorectal surgery RCTs have all employed quality assurance mechanisms to reduce risk of performance bias. Further research is indicated to investigate adopting objective assessment tools for quality assurance within multicenter RCTs.
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Long-term outcomes of the australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer: the Australasian Laparoscopic Colon Cancer Study trial. Ann Surg 2013; 256:915-9. [PMID: 23154392 DOI: 10.1097/sla.0b013e3182765ff8] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE : We report a multicentered randomized controlled trial across Australia and New Zealand comparing laparoscopic-assisted colon resection (LCR) with open colon resection (OCR) for colon cancer. BACKGROUND : Colon cancer is a significant worldwide health issue. This trial investigated whether the short-term benefits associated with LCR for colon cancer could be achieved safely, without survival disadvantages, in our region. METHODS : A total of 601 patients with potentially curable colon cancer were randomized to receive LCR or OCR. Primary endpoints were 5-year overall survival, recurrence-free survival, and freedom from recurrence rates, compared using an intention-to-treat analysis. RESULTS : On April 5, 2010, 587 eligible patients were followed for a median of 5.2 years (range, 1 week-11.4 years) with 5-year confirmed follow-up data for survival and recurrence on 567 (96.6%). Significant differences between the 2 trial groups were as follows: LCR patients were older at randomization, and their pathology specimens showed smaller distal resection margins; OCR patients had some worse pathology parameters, but there were no differences in disease stages. There were no significant differences between the LCR and OCR groups in 5-year follow-up of overall survival (77.7% vs 76.0%, P = 0.64), recurrence-free survival (72.7% vs 71.2%, P = 0.70), or freedom from recurrence (86.2% vs 85.6%, P = 0.85). CONCLUSIONS : In spite of some differences in short-term surrogate oncological markers, LCR was not inferior to OCR in direct measures of survival and disease recurrence. These findings emphasize the importance of long-term data in formulating evidence-based practice guidelines.
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Abstract
The use of robotic assistance facilitates minimally invasive surgery and has been widely adopted across multiple specialties. This article reviews the published literature on use of this technology for treatment of oncologic conditions. PubMed searches were performed for articles published between 2000 and 2012 using the keywords "robotic" or "robotic surgery" in conjunction with "oncology" or "cancer." Although the most common use for robotics was to treat urologic oncologic conditions, it has also been widely adopted for gynecologic, general, thoracic, and head and neck surgeries. For several procedures, there is evidence that robotics offers short-term benefits such as shorter lengths of stay and lower intraoperative blood loss, with safety profiles and oncologic outcomes comparable to open or conventional laparoscopic approaches. However, long-term oncologic outcomes are generally lacking, and robotic surgeries are more costly than open or laparoscopic surgeries. Robotic technology is widely used in oncologic surgery with demonstrated short-term advantages. However, whether the benefits of robotics justify the higher costs warrant large comparative effectiveness studies with long-term outcomes.
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Affiliation(s)
- Hua-Yin Yu
- Department of Urology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
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Kang CY, Carmichael JC, Friesen J, Stamos MJ, Mills S, Pigazzi A. Robotic-Assisted Extralevator Abdominoperineal Resection in the Lithotomy Position: Technique and Early Outcomes. Am Surg 2012. [DOI: 10.1177/000313481207801004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Extralevator abdominoperineal resection (E-APR) has been advocated as a superior procedure to achieve negative circumferential resection margins (CRMs) for sphincter-invading rectal cancers. An open total mesorectal excision is performed followed by perineal dissection with resection of the levators in the prone position. We describe a novel minimally invasive robotic approach carried out in the lithotomy position. Using the robotic arms to dissect the rectum and divide the levator fibers at their origin, the dissection is carried out in the ischiorectal space as distally as possible. From May to July 2011, six cases of robotic E-APR for rectal cancer were performed. The mean age was 54.5 years old. Mean operating time was 335 minutes. Mean estimated blood loss was 250 mL. There were no conversions to the open approach. A cylindrical specimen was obtained in all patients without perforation. All CRMs were negative. Mean hospital stay was 5 days. Two patients developed perineal wound infections and one developed a small bowel obstruction postoperatively. Robotic-assisted E-APR performed in the lithotomy position is safe and feasible. Future studies are needed to define the benefits of this technique.
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Affiliation(s)
- Celeste Y. Kang
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
| | - Joseph C. Carmichael
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
| | - Jeffrey Friesen
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
| | - Michael J. Stamos
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
| | - Steven Mills
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
| | - Alessio Pigazzi
- From the Department of Surgery, University of California, Irvine, School of Medicine, Irvine, California
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Cone MM, Herzig DO, Diggs BS, Rea JD, Hardiman KM, Lu KC. Effect of surgical approach on 30-day mortality and morbidity after elective colectomy: a NSQIP study. J Gastrointest Surg 2012; 16:1212-7. [PMID: 22402957 DOI: 10.1007/s11605-012-1860-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 02/26/2012] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study was to evaluate the laparoscopic approach and pre- and postoperative conditions as predictors of 30-day mortality and morbidity in elective colectomy. METHODS Elective colectomies were identified in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression was used to model 30-day mortality and morbidity following elective colectomy. Propensity scores were calculated to decrease selection bias. RESULTS During the period studied, 14,321 patients underwent open colectomy and 10,409 underwent laparoscopic colectomy. Factors that significantly influenced mortality included male gender [odds ratio (OR) 1.4, confidence interval (CI) 1.07-1.9]; age (OR 1.07, CI 1.05-1.08); comorbidities including dyspnea, ascites, congestive heart failure, dialysis, or disseminated cancer; and postoperative conditions including reintubation (OR 2.6, CI 1.6-4.0), renal failure (OR 3.8, CI 2.1-6.9), stroke (OR 6.44, CI 2.4-17.6), and septic shock (OR 13.1, CI 8.76-19.4). While laparoscopy was not independently associated with mortality, it was associated with decreased postoperative morbidity including reintubation (OR 0.74, CI 0.59-0.91), renal failure (OR 0.60, CI 0.4-0.91), septic shock (OR 0.74, CI 0.59-0.92), wound infection (OR 0.58, CI0.44-0.77), and pneumonia (OR 0.71, CI 0.59-0.86). CONCLUSIONS Based on this analysis, laparoscopy was associated with a decrease in 30-day postoperative morbidity for colectomy. However, after adjusting for preoperative comorbidities and postoperative morbidities, laparoscopy did not independently influence mortality after colectomy.
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Affiliation(s)
- Molly M Cone
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239-3098, USA
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Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study. Dis Colon Rectum 2012; 55:42-50. [PMID: 22156866 DOI: 10.1097/dcr.0b013e318239341f] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence demonstrates short-term benefits of laparoscopic surgery for colon cancer. The situation for rectal cancer is less clear. OBJECTIVES This review assessed the use and short-term outcomes of elective open and laparoscopic colon and rectal cancer resections within an area health service. DESIGN This was a multicenter, retrospective review of a prospective database. SETTINGS All elective colon and rectal cancer resections in the western zone of Sydney South West Area Health Service from 2001 until 2008 were included. PATIENTS Included were 1721 patients who underwent either a laparoscopic colon (n = 434) or rectal (n = 157) resection or an open colon (n = 742) or rectal (n = 388) resection. MAIN OUTCOME MEASURES : Outcome measures included operating time, blood loss, adequacy of resection, conversion rate, intensive care unit admission, length of stay, and 26 acute postoperative complications. RESULTS Patients were matched for age, sex, ASA, BMI, and tumor stage. Laparoscopic surgery increased in frequency. Fewer patients experienced a complication in both the laparoscopic colon (28.8 vs 54.4%; p < 0.0001) and rectal (41.4 vs 60.3%; p < 0.0001) group irrespective of age. Laparoscopic operating time for colon and rectal cancer was 24.1 minutes (p < 0.0001) and 25.8 minutes (p < 0.0001) longer, with a low conversion-to-open rate (6.5% and 8.3%; p = 0.44). Laparoscopic surgery resulted in fewer transfusions (0.4 vs 0.7 units; p = 0.0028) and length of stay (7 vs 10 days; p = 0.0011) for colon cancers, and reduced intraoperative hemoglobin drop (20.5 vs 24.8; p = 0.029) and intensive care unit admissions (26.8 vs 36.3%; p = 0.032) for rectal cancers. LIMITATIONS : This was a nonrandomized study with rectal cancers more often resected with the open technique (71.2 vs 28.8%; p < 0.001). CONCLUSIONS Within an area health service, elective laparoscopic resection for colon and rectal cancer had improved short-term outcomes in comparison with open surgery.
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Robot-assisted laparoscopic surgery of the colon and rectum. Surg Endosc 2011; 26:1-11. [PMID: 21858568 DOI: 10.1007/s00464-011-1867-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 05/31/2011] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Laparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery. METHODS A systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection. RESULTS Thirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean). CONCLUSIONS Robotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.
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Laparoscopic Colorectal Surgery Is Associated With a Higher Intraoperative Complication Rate Than Open Surgery. Ann Surg 2011; 253:35-43. [DOI: 10.1097/sla.0b013e318204a8b4] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ong EJS, Stevenson ARL. Current state of laparoscopic rectal cancer surgery in Australasia. ANZ J Surg 2010; 81:281-6. [DOI: 10.1111/j.1445-2197.2010.05590.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bartels SAL, Vlug MS, Ubbink DT, Bemelman WA. Quality of life after laparoscopic and open colorectal surgery: A systematic review. World J Gastroenterol 2010; 16:5035-41. [PMID: 20976839 PMCID: PMC2965279 DOI: 10.3748/wjg.v16.i40.5035] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study was a systematic review of the available evidence on quality of life in patients after laparoscopic or open colorectal surgery. A systematic review was performed of all randomized clinical trials (RCTs) that compared laparoscopic with open colorectal surgery. Study selection, quality assessment and data extraction were carried out independently by two reviewers. Primary endpoint was quality of life after laparoscopic and open colorectal surgery, as assessed by validated questionnaires. The search resulted in nine RCTs that included 2263 patients. Short- and long-term results of these RCTs were described in 13 articles. Postoperative follow-up ranged from 2 d to 6.7 years. Due to clinical heterogeneity, no meta-analysis could be conducted. Four RCTs did not show any difference in quality of life between laparoscopic or open colorectal surgery. The remaining five studies reported a better quality of life in favor of the laparoscopic group on a few quality of life scales at time points ranging from 1 wk to 2 years after surgery. In conclusion, based on presently available high-level evidence, this systematic review showed no clinically relevant differences in postoperative quality of life between laparoscopic and open colorectal surgery.
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Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Hewett PJ, Rieger NA, Smith JS, Solomon MJ, Stevenson ARL. Ethical issues with the disclosure of surgical trial short-term data. ANZ J Surg 2010; 81:125-31. [DOI: 10.1111/j.1445-2197.2010.05433.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Hewett PJ, Rieger NA, Smith JS, Solomon MJ, Stevenson ARL. Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection. Br J Surg 2009; 97:86-91. [PMID: 19937975 DOI: 10.1002/bjs.6785] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented. METHODS A total of 592 eligible patients were entered and studied from 1998 to 2005. RESULTS Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed; 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70.3(11.0) years). Forty-three laparoscopic operations (14.6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0.002), owing primarily to a lower rate in patients aged 70 years or more (P = 0.002). Fewer patients in the laparoscopic group experienced any complication (P = 0.035), especially patients aged 70 years or above (P = 0.019). CONCLUSION Treatment choices for colonic cancer depend principally upon disease-free survival; however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection. REGISTRATION NUMBER NCT00202111 (http://www.clinicaltrials.gov).
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Affiliation(s)
- R A Allardyce
- Department of Surgery, University of Otago, Christchurch, New Zealand.
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