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Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic. Updates Surg 2022; 74:1271-1279. [PMID: 35606625 PMCID: PMC9126695 DOI: 10.1007/s13304-022-01283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022]
Abstract
Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.
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Abdel-Dayem M, Maradi Thippeswamy K, Haray P. A Structured Modular Approach: The Answer to Training in Laparoscopic Colorectal Surgery. Surg Innov 2021; 28:479-484. [PMID: 33829917 DOI: 10.1177/15533506211008079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bakground: Laparoscopic techniques are now an integral part of the operative management of colorectal diseases. However, the specialist training that is required for this is not uniformly available. There is, therefore, a need for a structured competency-based training method so that trainees can navigate the learning curve safely. Aim. To develop a modular structured training programme for laparoscopic colorectal surgery (LCS) with the capability of ensuring competency-based progression from a novice level to independent operator. Methodology. Over the past decade, we have developed a structured approach, starting with junior surgical trainees and progressing through to consultant level, with 7 clearly defined levels of progression attending courses to achieving a trainer status. This approach allows trainees to maintain objective records of their progression and trainers to provide targeted learning opportunities. It also allows for several trainees of varying experience to be trained during the same procedure. Conclusion. Our structured training module for junior surgeons has successfully produced several competent laparoscopic colorectal surgeons in the United Kingdom and around the world. This approach may also be adaptable to training in other laparoscopic procedures as the levels of progression are generic and not procedure-specific.
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Affiliation(s)
- Mahmoud Abdel-Dayem
- Department of Colorectal Surgery, 8911Prince Charles Hospital- Merthyr Tydfil, Merthyr Tydfil, UK
| | | | - Puthucode Haray
- Department of Colorectal Surgery, 8911Prince Charles Hospital- Merthyr Tydfil, Merthyr Tydfil, UK.,Department of Surgery, 6654University of South Wales, Pontypridd, UK
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3
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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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Amin-Tai H, Elnaim ALK, Wong MPK, Sagap I. Acquiring Advanced Laparoscopic Colectomy Skills - The Issues. Malays J Med Sci 2020; 27:24-35. [PMID: 33154699 PMCID: PMC7605826 DOI: 10.21315/mjms2020.27.5.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/14/2020] [Indexed: 10/28/2022] Open
Abstract
Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England's Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves pre-clinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.
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Affiliation(s)
- Hizami Amin-Tai
- Department of Surgery, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | | | - Michael Pak Kai Wong
- School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ismail Sagap
- Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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5
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Gehrman J, Angenete E, Björholt I, Lesén E, Haglind E. Cost-effectiveness analysis of laparoscopic and open surgery in routine Swedish care for colorectal cancer. Surg Endosc 2020; 34:4403-4412. [PMID: 31630289 DOI: 10.1007/s00464-019-07214-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopic surgery for colorectal cancer has been shown in clinical trials to be effective regarding short-term outcomes and oncologically safe. Health economic analyses have been performed early in the learning curve when adoption of laparoscopic surgery was not extensive. This cost-effectiveness analysis evaluates laparoscopic versus open colorectal cancer surgery in Swedish routine care. METHODS In this national retrospective cohort study, data were retrieved from the Swedish ColoRectal Cancer Registry. Clinical effectiveness, resource use and unit costs were derived from this and other sources with nationwide coverage. The study period was 2013 and 2014 with 1 year follow-up. Exclusion criterion comprised cT4-tumors. Clinical effectiveness was estimated in a composite endpoint of all-cause resource-consuming events in inpatient care, readmissions and deaths up to 90 days postoperatively. Up to 1 year, events predefined as related to the primary surgery were included. Costs included resource-consuming events, readmissions and sick leave and were estimated for both the society and healthcare. Multivariable regression analyses were used to adjust for differences in baseline characteristics between the groups. RESULTS After exclusion of cT4 tumors, the cohort included 7707 patients who underwent colorectal cancer surgery: 6060 patients in the open surgery group and 1647 patients in the laparoscopic group. The mean adjusted difference in clinical effectiveness between laparoscopic and open colorectal cancer surgery was 0.23 events (95% CI 0.12 to 0.33). Mean adjusted differences in costs (open minus laparoscopic surgery) were $4504 (95% CI 2257 to 6799) and $4480 (95% CI 2739 to 6203) for the societal and the healthcare perspective respectively. In both categories, resource consuming events in inpatient care were the main driver of the results. CONCLUSION In a national cohort, laparoscopic colorectal cancer surgery was associated with both superior outcomes for clinical effectiveness and cost versus open surgery.
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Affiliation(s)
- Jacob Gehrman
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden. .,PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden.
| | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden
| | - Ingela Björholt
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden.,PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden
| | - Eva Lesén
- PharmaLex (Formerly Nordic Health Economics), Medicinaregatan 8, 413 90, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, Sahlgrenska Academy, University of Gothenburg, 416 50, Gothenburg, Sweden
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6
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Völkel V, Draeger T, Schnitzbauer V, Gerken M, Benz S, Klinkhammer-Schalke M, Fürst A. Surgical treatment of rectal cancer patients aged 80 years and older—a German nationwide analysis comparing short- and long-term survival after laparoscopic and open tumor resection. Eur J Surg Oncol 2019; 45:1607-1612. [DOI: 10.1016/j.ejso.2019.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/28/2019] [Accepted: 05/08/2019] [Indexed: 12/27/2022] Open
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7
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Elmore U, Vignali A, Rosati R, Valeri A, Silecchia G. SICE national survey: current state on the adoption of laparoscopic approach to the treatment of colorectal disease in Italy. Updates Surg 2018; 71:77-81. [PMID: 30470995 DOI: 10.1007/s13304-018-0606-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Abstract
The real diffusion of laparoscopy for the treatment of colorectal diseases in Italy is largely unknown. The main purpose of the present study is to investigate among surgeons dedicated to minimally invasive surgery, the volume of laparoscopic colorectal procedures, the type of operation performed in comparison to traditional approach, the indication for surgery (benign and malignant) and to evaluate the different types of technologies used. A structured questionnaire was developed in collaboration with an international market research institute and the survey was published online; invitation to participate to the survey was issued among the members of the Italian Society of Endoscopic Surgery (SICE). 211 surgeons working in 57 surgical departments in Italy fulfilled and answered the online survey. A total of 6357 colorectal procedures were recorded during the year 2015 of which 4104 (64.1%) were performed using a minimally invasive approach. Colon and rectal cancer were the most common indications for laparoscopic approach (83.1%). Left colectomy was the operation most commonly performed (41.8%), while rectal resection accounted for 23.5% of the cases. Overall conversion rate was 5.9% (242/4104). Full HD standard technology was available and routinely used in all the responders' centers. The proportion of colorectal resections that are carried out laparoscopically in dedicated centers has now reached valuable levels with a low conversion rate.
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Affiliation(s)
- Ugo Elmore
- Department of Surgery, San Raffaele Scientific Institute, University Vita Salute, Milan, Italy.
- SICE Collaborative Group, Rome, Italy.
| | - Andrea Vignali
- Department of Surgery, San Raffaele Scientific Institute, University Vita Salute, Milan, Italy
| | - Riccardo Rosati
- Department of Surgery, San Raffaele Scientific Institute, University Vita Salute, Milan, Italy
| | - Andrea Valeri
- Department of Surgery, Ospedale Careggi, Florence, Italy
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8
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Toward standardization of laparoscopic resection for colorectal cancer in developing countries: A step by step module. J Egypt Natl Canc Inst 2017; 29:135-140. [PMID: 28668495 DOI: 10.1016/j.jnci.2017.04.003] [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] [Received: 01/21/2017] [Revised: 03/19/2017] [Accepted: 04/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption. OBJECTIVE To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles. PATIENTS AND METHODS This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed. RESULTS The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient. CONCLUSION Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting.
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9
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Buchs NC, Wynn G, Austin R, Penna M, Findlay JM, Bloemendaal ALA, Mortensen NJ, Cunningham C, Jones OM, Guy RJ, Hompes R. A two-centre experience of transanal total mesorectal excision. Colorectal Dis 2016; 18:1154-1161. [PMID: 27218423 DOI: 10.1111/codi.13394] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/02/2016] [Indexed: 12/16/2022]
Abstract
AIM Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two-centre experience of this technique, focusing on the short-term and oncological outcome. METHOD From May 2013 to May 2015, 40 selected patients with histologically proven rectal adenocarcinoma underwent TaTME in two institutions and were prospectively entered on an online international registry. RESULTS Forty patients (80% men, mean body mass index 27.4 kg/m2 ) requiring TME underwent TaTME. Procedures included low anterior resection (n = 31), abdominoperineal excision (n = 7) and proctocolectomy (n = 2). A minimally invasive approach was attempted in all cases, with three conversions. The mean operation time was 368 min and 16 patients (40%) had a synchronous abdominal and transanal approach. There was no mortality and 16 postoperative complications occurred, of which 68.8% were minor. The median length of stay was 7.5 (3-92) days. A complete or near-complete TME specimen was delivered in 39 (97.5%) cases with a mean number of 20 lymph nodes harvested. R0 resection was achieved in 38 (95%) patients. After a median follow-up of 10.7 months, there were no local recurrences and six (15%) patients had developed distant metastases. CONCLUSION TaTME appears to be feasible, safe and reproducible, without compromising the oncological principles of rectal cancer surgery. It is an attractive option for patients for whom laparoscopy is likely to be particularly difficult. These encouraging results should encourage larger studies with assessment of long-term function and the oncological outcome.
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Affiliation(s)
- N C Buchs
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - G Wynn
- ICENI Centre, Colchester Hospital University Foundation Trust, Colchester, UK
| | - R Austin
- ICENI Centre, Colchester Hospital University Foundation Trust, Colchester, UK
| | - M Penna
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - J M Findlay
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - A L A Bloemendaal
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - O M Jones
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R J Guy
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
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Tikuisis R, Miliauskas P, Lukoseviciene V, Samalavicius N, Dulskas A, Zabuliene L, Zabulis V, Urboniene J. Transversus abdominis plane block for postoperative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial. Tech Coloproctol 2016; 20:835-844. [DOI: 10.1007/s10151-016-1550-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
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Panteleimonitis S, Ahmed J, Harper M, Parvaiz A. Critical analysis of the literature investigating urogenital function preservation following robotic rectal cancer surgery. World J Gastrointest Surg 2016; 8:744-754. [PMID: 27933136 PMCID: PMC5124703 DOI: 10.4240/wjgs.v8.i11.744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/19/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To analyses the current literature regarding the urogenital functional outcomes of patients receiving robotic rectal cancer surgery.
METHODS A comprehensive literature search of electronic databases was performed in October 2015. The following search terms were applied: “rectal cancer” or “colorectal cancer” and robot* or “da Vinci” and sexual or urolog* or urinary or erect* or ejaculat* or impot* or incontinence. All original studies examining the urological and/or sexual outcomes of male and/or female patients receiving robotic rectal cancer surgery were included. Reference lists of all retrieved articles were manually searched for further relevant articles. Abstracts were independently searched by two authors.
RESULTS Fifteen original studies fulfilled the inclusion criteria. A total of 1338 patients were included; 818 received robotic, 498 laparoscopic and 22 open rectal cancer surgery. Only 726 (54%) patients had their urogenital function assessed via means of validated functional questionnaires. From the included studies, three found that robotic rectal cancer surgery leads to quicker recovery of male urological function and five of male sexual function as compared to laparoscopic surgery. It is unclear whether robotic surgery offers favourable urogenital outcomes in the long run for males. In female patients only two studies assessed urological and three sexual function independently to that of males. In these studies there was no difference identified between patients receiving robotic and laparoscopic rectal cancer surgery. However, in females the presented evidence was very limited making it impossible to draw any substantial conclusions.
CONCLUSION There seems to be a trend towards earlier recovery of male urogenital function following robotic surgery. To evaluate this further, larger well designed studies are required.
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12
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de'Angelis N, Lizzi V, Azoulay D, Brunetti F. Robotic Versus Laparoscopic Right Colectomy for Colon Cancer: Analysis of the Initial Simultaneous Learning Curve of a Surgical Fellow. J Laparoendosc Adv Surg Tech A 2016; 26:882-892. [PMID: 27454105 DOI: 10.1089/lap.2016.0321] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Robotic surgery was introduced to overcome laparoscopic drawbacks. This study aimed to compare the learning curve of robotic-assisted right colectomy (RRC) versus laparoscopic-assisted right colectomy (LRC) for colon cancer with respect to operative times and perioperative outcomes. In addition, the health-related costs associated with both procedures were analyzed and compared. METHODS Between 2012 and 2015, 30 consecutive patients underwent RRC and 50 patients LRC for colon cancer. All procedures were performed by a surgical fellow novice in minimally invasive colorectal surgery. The operative time and the cumulative sum method were used to evaluate the learning curve of RRC versus LRC. RESULTS The mean operative times were 200.5 minutes for RRC and 204.1 minutes for LRC (P = .408) and showed a significant decrease over consecutive procedures (P < .0001). The number of cases necessary to identify a drop in the operative time was 16 for RRC and 25 for LRC. RRC procedures were associated with significantly reduced blood loss (P = .012). Two patients (4%) in the LRC group were converted to laparotomy, whereas no conversion was required in the RRC group. Surgery-related costs were significantly more expensive for RRC, but when combined with the hospitalization-related costs, LRC and RRC did not differ (P = .632). CONCLUSIONS Both robotic and laparoscopic operative times decrease rapidly with practice. However, RRC is associated with a faster learning curve than LRC. The simultaneous development of these two minimally invasive approaches appears to be safe and feasible with acceptable health-related costs.
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Affiliation(s)
- Nicola de'Angelis
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Vincenzo Lizzi
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Daniel Azoulay
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
| | - Francesco Brunetti
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri Mondor Hospital , AP-HP, Université Paris Est-UPEC, Créteil, France
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13
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Lim S, Kim JH, Baek SJ, Kim SH, Lee SH. Comparison of perioperative and short-term outcomes between robotic and conventional laparoscopic surgery for colonic cancer: a systematic review and meta-analysis. Ann Surg Treat Res 2016; 90:328-39. [PMID: 27274509 PMCID: PMC4891524 DOI: 10.4174/astr.2016.90.6.328] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/12/2016] [Accepted: 03/14/2016] [Indexed: 12/14/2022] Open
Abstract
Purpose Reports from several case series have described the feasibility and safety of robotic surgery (RS) for colonic cancer. Experience is still limited in robotic colonic surgery, and a few meta-analysis has been conducted to integrate the results for colon cancer specifically. We conducted a systematic review of the available evidence comparing the surgical safety and efficacy of RS with that of conventional laparoscopic surgery (CLS) for colonic cancer. Methods We searched English databases (MEDLINE, Embase, and Cochrane Library), and Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi). Dichotomous variables were pooled using the risk ratio, and continuous variables were pooled using the mean difference (MD). Results The present study found that the RS group had a shorter time to resumption of a regular diet (MD, –0.62 days; 95% CI, –0.97 to –0.28), first passage of flatus (MD, –0.44 days; 95% CI, –0.66 to –0.23) and defecation (MD, –0.62 days; 95% CI, –0.77 to –0.47). Also, RS was associated with a shorter hospital stay (MD, –0.69 days; 95% CI, –1.12 to –0.26), a lower estimated blood loss (MD, –19.49 mL; 95% CI, –27.10 to –11.89) and a longer proximal margin (MD, 2.29 cm; 95% CI, 1.11-3.47). However, RS was associated with a longer surgery time (MD, 51.00 minutes; 95% CI, 39.38–62.62). Conclusion We found that the potential benefits of perioperative and short-term outcomes for RS than for CLS. For a more accurate understanding of RS for colonic cancer patients, robust comparative studies and randomized clinical trials are required.
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Affiliation(s)
- Sungwon Lim
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jin Hee Kim
- Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea
| | - Se-Jin Baek
- Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seon-Hahn Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seon Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon, Korea
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Buchs NC, Nicholson GA, Yeung T, Mortensen NJ, Cunningham C, Jones OM, Guy R, Hompes R. Transanal rectal resection: an initial experience of 20 cases. Colorectal Dis 2016; 18:45-50. [PMID: 26639062 DOI: 10.1111/codi.13227] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/14/2015] [Indexed: 12/11/2022]
Abstract
AIM Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique. METHOD From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database. RESULTS Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21). CONCLUSION TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.
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Affiliation(s)
- N C Buchs
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - G A Nicholson
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - T Yeung
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - O M Jones
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Guy
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
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15
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Tudor ECG, Yang W, Brown R, Mackey PM. Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery. Ann R Coll Surg Engl 2015; 97:530-3. [PMID: 26414363 DOI: 10.1308/rcsann.2015.0018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Rectus sheath catheters (RSCs) are increasingly being used to provide postoperative analgesia following laparotomy for colorectal surgery. Little is known about their efficacy in comparison with epidural infusion analgesia (EIA). They are potentially better as they avoid the recognised complications associated with EIA. This study compares these two methods of analgesia. Outcomes include average pain scores, time to mobilisation and length of stay. Methods This was a 33-month single centre observational study including all patients undergoing elective open or laparoscopic-converted-to-open colorectal resection for both benign and malignant disease. Patients received either EIA or RSCs. Data were collected prospectively and analysed retrospectively. Results A total of 95 patients were identified. Indications for surgery, operation and complications were recorded. The mean time to mobilisation was significantly shorter in patients who had RSCs compared with EIA patients (2.4 vs 3.5 days, p<0.05). There was no difference in postoperative pain scores or length of stay. Conclusions RSCs provide equivalent analgesia to EIA and avoid the recognised potential complications of EIA. They are associated with a shorter time to mobilisation. Their use should be adopted more widely.
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Affiliation(s)
- E C G Tudor
- Taunton and Somerset NHS Foundation Trust , UK
| | - W Yang
- Taunton and Somerset NHS Foundation Trust , UK
| | - R Brown
- Taunton and Somerset NHS Foundation Trust , UK
| | - P M Mackey
- Taunton and Somerset NHS Foundation Trust , UK
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16
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Klugsberger B, Haas D, Oppelt P, Neuner L, Shamiyeh A. Current State of Laparoscopic Colonic Surgery in Austria: A National Survey. J Laparoendosc Adv Surg Tech A 2015; 25:976-81. [PMID: 26599418 DOI: 10.1089/lap.2015.0373] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Several studies have demonstrated that laparoscopic colonic resection has significant benefits in comparison with open approaches in patients with benign and malignant disease. The proportion of colonic and rectal resections conducted laparoscopically in Austria is not currently known; the aim of this study was to evaluate the current status of laparoscopic colonic surgery in Austria. MATERIALS AND METHODS A questionnaire was distributed to all general surgical departments in Austria. In collaboration with IMAS, an Austrian market research institute, an online survey was used to identify laparoscopic and open colorectal resections performed in 2013. The results were compared with data from the National Hospital Morbidity Database (NHMD), in which administrative in-patient data were also collected from all general surgical departments in Austria in 2013. RESULTS Fifty-three of 99 surgical departments in Austria responded (53.5%); 4335 colonic and rectal resections were carried out in the participating departments, representing 50.5% of all NHMD-recorded colorectal resections (n = 8576) in Austria in 2013. Of these 4335 colonic and rectal resections, 2597 (59.9%) were carried out using an open approach, 1674 (38.6%) were laparoscopic, and an exact classification was not available for 64 (1.5%). Among the NHMD-recorded colonic and rectal resections, 6342 (73.9%) were carried out with an open approach, and 2234 (26.1%) were laparoscopic. CONCLUSIONS The proportion of colorectal resections that are carried out laparoscopically is low (26.1%). Technical challenges and a learning curve with a significant number of cases may be reasons for the slow adoption of laparoscopic colonic surgery.
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Affiliation(s)
- Bettina Klugsberger
- 1 Second Surgical Department, Kepler University Hospital , Linz, Austria .,2 Linz Training and Research Center for Surgery and Oncology, Kepler University Hospital , Linz, Austria
| | - Dietmar Haas
- 3 Department of Obstetrics and Gynecology, Kepler University Hospital , Linz, Austria .,4 Department of Gynecology, Erlangen University Hospital , Erlangen, Germany
| | - Peter Oppelt
- 3 Department of Obstetrics and Gynecology, Kepler University Hospital , Linz, Austria .,4 Department of Gynecology, Erlangen University Hospital , Erlangen, Germany
| | - Ludwig Neuner
- 5 Department of Anesthesiology and Intensive Care, Freistadt General Hospital , Freistadt, Austria
| | - Andreas Shamiyeh
- 1 Second Surgical Department, Kepler University Hospital , Linz, Austria .,2 Linz Training and Research Center for Surgery and Oncology, Kepler University Hospital , Linz, Austria
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17
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Lee SH, Lim S, Kim JH, Lee KY. Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis. Ann Surg Treat Res 2015; 89:190-201. [PMID: 26448918 PMCID: PMC4595819 DOI: 10.4174/astr.2015.89.4.190] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/13/2015] [Accepted: 07/04/2015] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Robotic surgery (RS) overcomes the limitations of previous conventional laparoscopic surgery (CLS). Although meta-analyses have been published recently, our study evaluated the latest comparative surgical, urologic, and sexual results for rectal cancer and compares RS with CLS in patients with rectal cancer only. METHODS We searched three foreign databases (Ovid-MEDLINE, Ovid-Embase, and Cochrane Library) and five Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi) during July 2013. The Cochrane Risk of Bias and the Methodological Index for Non-Randomized were utilized to evaluate quality of study. Dichotomous variables were pooled using the risk ratio (RR), and continuous variables were pooled using the mean difference (MD). All meta-analyses were conducted with Review Manager, V. 5.3. RESULTS Seventeen studies involving 2,224 patients were included. RS was associated with a lower rate of intraoperative conversion than that of CLS (RR, 0.28; 95% confidence interval [CI], 0.15-0.54). Time to first flatus was short (MD, -0.13; 95% CI, -0.25 to -0.01). Operating time was longer for RS than that for CLS (MD, 49.97; 95% CI, 20.43-79.52, I(2) = 97%). International Prostate Symptom Score scores at 3 months better RS than CLS (MD, -2.90; 95% CI, -5.31 to -0.48, I(2) = 0%). International Index of Erectile Function scores showed better improvement at 3 months (MD, -2.82; 95% CI, -4.78 to -0.87, I(2) = 37%) and 6 months (MD, -2.15; 95% CI, -4.08 to -0.22, I(2) = 0%). CONCLUSION RS appears to be an effective alternative to CLS with a lower conversion rate to open surgery, a shorter time to first flatus and better recovery in voiding and sexual function. RS could enhance postoperative recovery in patients with rectal cancer.
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Affiliation(s)
- Seon Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon, Korea
| | - Sungwon Lim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jin Hee Kim
- Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea
| | - Kil Yeon Lee
- Department of Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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18
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Zarak A, Castillo A, Kichler K, de la Cruz L, Tamariz L, Kaza S. Robotic versus laparoscopic surgery for colonic disease: a meta-analysis of postoperative variables. Surg Endosc 2015; 29:1341-7. [PMID: 25847139 DOI: 10.1007/s00464-015-4197-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/15/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION An increasing number of studies have been published since the introduction of robotic technology into general surgery. Gastrointestinal surgery is an area of special interest for the robotic surgeon. Colonic surgery can be challenging depending on the disease and the operative approach. We seek to perform a meta-analysis comparing robotic surgery against laparoscopic surgery in this particular field. MATERIALS AND METHODS We performed a systematic search of MEDLINE database from January 2001 to July 2013 supplemented by manual searches of bibliographies of key relevant articles. Randomized controlled trials and cohort studies were selected for review and for collection of postoperative data (length of stay, time to first flatus and complications). RESULTS After careful review, nine studies were considered for analysis. Non-pooled data showed a slight trend toward laparoscopy with increased number of events without statistical significance. Pooled data demonstrated a statistical significance for return to bowel function in the right and mixed robotic colectomy arm (WSMD -0.33, 95 % CI -0.5, -0.1; p < 0.005 and WSMD -0.26, 95 % CI -0.51, 0.0; p = 0.05). Pooled data of length of stay and complications showed no statistical significance between robotic and laparoscopic colonic surgery. DISCUSSION Robotic surgery is a comparable option when dealing with colonic disease, either benign or malignant. No difference in complication rate or length of stay was found when comparing the two. Robotic surgery appears to have an advantage over laparoscopy in regards to return of bowel function when dealing with right colectomies.
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Affiliation(s)
- Alberto Zarak
- Department of Surgery, University of Miami, 5301 S Congress Ave, Atlantis, FL, 33462, USA,
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19
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Di Fabio F, Barkhatov L, Bonadio I, Dimovska E, Fretland ÅA, Pearce NW, Troisi RI, Edwin B, Abu Hilal M. The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: A multicenter study. Surgery 2015; 157:1046-54. [PMID: 25835216 DOI: 10.1016/j.surg.2015.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/16/2014] [Accepted: 01/11/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic liver surgery is expanding. Most laparoscopic liver resections for colorectal carcinoma metastases are performed subsequent to the resection of the colorectal primary, raising concerns about the feasibility and safety of advanced laparoscopic liver surgery in the context of an abdomen with possible postoperative adhesions. The aim was to compare the outcome of laparoscopic hepatectomy for colorectal metastases after open versus laparoscopic colorectal surgery. METHODS This observational, multicenter study reviewed 394 patients undergoing laparoscopic minor and major liver resection for colorectal carcinoma metastases. Main outcome measures were intraoperative unfavorable incidents and short-term results in patients who had previous open versus laparoscopic colorectal cancer surgery. RESULTS Three hundred six patients (78%) had prior open and 88 (22%) had prior laparoscopic colorectal resection. Laparoscopic major hepatectomies were undertaken in 63 (16%). Intraoperative unfavorable incidents during laparoscopic liver surgery were significantly higher among patients who had prior open colorectal surgery (26%) compared with the laparoscopic group (14%; P = .017). Positive resection margins and postoperative complications were not associated with the approach adopted for the resection of the primary cancer. On multivariate logistic regression analysis, intraoperative unfavorable incidents were associated significantly only with prior open colorectal surgery (odds ratio, 2.8; P = .006) and laparoscopic major hepatectomy (odds ratio, 2.4; P = .009). CONCLUSION Laparoscopic minor hepatectomy can be performed safely in patients who have undergone previous open colorectal surgery. Laparoscopic major hepatectomy after open colorectal surgery may be challenging. Careful risk assessment in the decision-making process is required not to compromise patient safety and to guarantee the expected benefits from the minimally invasive approach.
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Affiliation(s)
- Francesco Di Fabio
- Department of Colorectal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Leonid Barkhatov
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hepato-Biliary and Pancreatic Surgery, Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Italo Bonadio
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eleonora Dimovska
- Department of Hepato-Biliary and Pancreatic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Åsmund A Fretland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hepato-Biliary and Pancreatic Surgery, Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Neil W Pearce
- Department of Hepato-Biliary and Pancreatic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Roberto I Troisi
- Department of Hepato-Biliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Bjørn Edwin
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hepato-Biliary and Pancreatic Surgery, Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Mohammed Abu Hilal
- Department of Hepato-Biliary and Pancreatic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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20
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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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21
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Xiong B, Ma L, Huang W, Zhao Q, Cheng Y, Liu J. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies. J Gastrointest Surg 2015; 19:516-26. [PMID: 25394387 DOI: 10.1007/s11605-014-2697-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 11/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME). METHODS Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated. RESULTS Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups. CONCLUSIONS RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.
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Affiliation(s)
- Binghong Xiong
- Department of General Surgery, Peking University Shougang Hospital, No 9 Jinyuanzhuang Road, Shijingshan District, 100144, Beijing, People's Republic of China,
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22
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Rees M, Saklani A, Shah P, Haray P. A structured preceptorship programme for laparoscopic colorectal surgery in Wales: An early experience. J Minim Access Surg 2014; 10:185-9. [PMID: 25336818 PMCID: PMC4204261 DOI: 10.4103/0972-9941.141512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/29/2013] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION A single experienced laparoscopic colorectal surgeon introduced an outreach preceptorship programme (OPP) for laparoscopic colorectal surgery (LCS) in Wales with the aim of supporting consultants in the early stages of their learning curve, as well as to help avoid some of the problems faced by self-taught laparoscopic surgeons. The structured programme consisted of a minimum 1 day master class at the preceptor's operating theatre, followed by multiple outreach visits by the preceptor. The aim of this study was to evaluate the effectiveness and early experience of this programme. MATERIALS AND METHODS Clinical end-points (conversions, morbidity/mortality and length of hospital stay) were analysed from a prospectively maintained database. Evaluation of the programme was based on interviews with the preceptee surgeons performed by a neutral observer. RESULTS Between May 2008 and July 2010, 11 Consultants (six hospitals) were preceptored (two still in programme). 66 cases (20 in the master class, 46 as an outreach service) were performed as a part of this programme. CLINICAL OUTCOME Conversion rate and 30-day mortality was 1.5%. Morbidity was reported at 12% (8/66) and median length of stay was 6 days. Programme evaluation: All interviewed respondents found the master class and outreach service to be well-organised and would recommend it to their colleagues. The median number of outreach visits per hospital was 5. All the preceptees have performed independent cases since the programme. CONCLUSION This OPP delivers one-to-one coaching at the point of service delivery and has been shown to be effective in achieving safe transference of skills to those wishing to develop a service for LCS.
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Affiliation(s)
- Michael Rees
- Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, Wales, UK
| | - Avanish Saklani
- Department of Surgery, Princess of Wales Hospital, Bridgend, UK
| | - Parin Shah
- Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, Wales, UK
| | - Puthucode Haray
- Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, Wales, UK ; Department of Coloproctology, University of Glamorgan, Pontypridd, UK
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Abstract
Since its introduction, robotic surgery has been rapidly adopted to the extent that it has already assumed an important position in the field of general surgery. This rapid progress is quantitative as well as qualitative. In this review, we focus on the relatively common procedures to which robotic surgery has been applied in several fields of general surgery, including gastric, colorectal, hepato-biliary-pancreatic, and endocrine surgery, and we discuss the results to date and future possibilities. In addition, the advantages and limitations of the current robotic system are reviewed, and the advanced technologies and instruments to be applied in the near future are introduced. Such progress is expected to facilitate the widespread introduction of robotic surgery in additional fields and to solve existing problems.
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Affiliation(s)
- Se-Jin Baek
- Department of Surgery; Yonsei University College of Medicine; Seoul South Korea
| | - Seon-Hahn Kim
- Department of Surgery; Korea University College of Medicine; Seoul South Korea
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24
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Kang J, Kim IK, Kang SI, Sohn SK, Lee KY. Laparoscopic right hemicolectomy with complete mesocolic excision. Surg Endosc 2014; 28:2747-51. [PMID: 24718666 DOI: 10.1007/s00464-014-3521-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 03/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Complete mesocolic excision (CME) has recently been reemphasized as a technical approach for anatomical dissection during colon cancer surgery. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. In our practice, the patient lies in a modified lithotomy position. The first step is ileocolic area mobilization, followed by adequate retraction of the cecum laterally. This procedure enables discrimination of the ileocolic vessels and superior mesenteric vessels. Importantly, this method facilitates identification of the superior mesenteric vein (SMV), followed by the identification of the root of ileocolic pedicles. After that, sharp dissection along the SMV in an upward direction helps to safely identify the middle colic artery (MCA). Dissection then continues to the level of the origin of MCA, after which the right branch of MCA can be divided. METHODS A total of 128 consecutive patients (63 males) who underwent laparoscopic CME for right colon cancer by a single surgeon were analyzed in this study. RESULTS There was no conversion to open surgery. The median operation time was 192 min (interquartile range [IQR] 118-363 min). The median proximal and distal resection margins were 11 and 10 cm, respectively. The median number of harvested lymph nodes was 28 (IQR 3-88). There were six postoperative complications (4.6 %). The median hospital stay was 5 days (IQR 4-37 days). The video demonstrates a laparoscopic CME for a patient who had advanced distal ascending colon cancer. CONCLUSION In conclusion, identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure for containing all potential routes of metastatic tumors. Initial ileocecal mobilization with adequate counter traction of the cecum may be useful for novice surgeons attempting to identify the location of SMV during laparoscopic CME for right colon cancer.
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Affiliation(s)
- Jeonghyun Kang
- Department of Surgery, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea,
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25
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Ghezzi TL, Luca F, Valvo M, Corleta OC, Zuccaro M, Cenciarelli S, Biffi R. Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes. Eur J Surg Oncol 2014; 40:1072-9. [PMID: 24646748 DOI: 10.1016/j.ejso.2014.02.235] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 01/27/2014] [Accepted: 02/17/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce. METHODS The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared. RESULTS There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024). CONCLUSION RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.
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Affiliation(s)
- T L Ghezzi
- Division of Colorectal Surgery, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Ramiro Barcelos Street 2350, 90035-903 Porto Alegre, Brazil.
| | - F Luca
- Unit of Integrated Abdominal Surgery, Division of Abdominopelvic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
| | - M Valvo
- Unit of Integrated Abdominal Surgery, Division of Abdominopelvic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
| | - O C Corleta
- Department of Surgery and General Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - M Zuccaro
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
| | - S Cenciarelli
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
| | - R Biffi
- Division of Abdominopelvic Surgery, European Institute of Oncology, Milan, Italy
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Tanis PJ, Buskens CJ, Bemelman WA. Laparoscopy for colorectal cancer. Best Pract Res Clin Gastroenterol 2014; 28:29-39. [PMID: 24485253 DOI: 10.1016/j.bpg.2013.11.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/10/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.
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Affiliation(s)
- P J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
| | - C J Buskens
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Xiong B, Ma L, Zhang C, Cheng Y. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis. J Surg Res 2014; 188:404-14. [PMID: 24565506 DOI: 10.1016/j.jss.2014.01.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/05/2014] [Accepted: 01/16/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME. MATERIALS AND METHODS Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated. RESULTS Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME. CONCLUSIONS RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.
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Affiliation(s)
- Binghong Xiong
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Li Ma
- Department of Internal Medicine, Chongqing Huaxi Hospital, Chongqing, People's Republic of China
| | - CaiQuan Zhang
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yong Cheng
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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Godden AR, Marshall MJ, Grice AS, Daniels IR. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. Ann R Coll Surg Engl 2013. [PMID: 24165343 DOI: 10.1308/003588413x13629960049270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Epidural anaesthesia (EA) has been the accepted standard for postoperative analgesia in open abdominal surgery. However, it is not without significant risk. This study aimed to audit the effect of EA and ultrasonography placed rectus sheath catheters (RSCs) on analgesia as well as the incidence of postoperative complications following open colorectal cancer surgery. METHODS A three-year retrospective case note review was undertaken of all patients undergoing open colorectal cancer surgery at the Royal Devon and Exeter Hospital NHS Foundation Trust who received either EA or RSC for postoperative analgesia under the care of the senior authors. A single surgeon and single anaesthetist were practitioners. RESULTS The case notes of 120 patients were reviewed retrospectively: 85 patients had EA and 24 RSC while 11 patients were excluded from the study. The EA group experienced a significantly higher incidence of hypotension (systolic blood pressure <130 mmHg) than the RSC group on the first postoperative day (p=0.0001). There was no significant difference in pain score or opiate sparing properties between the groups (p=0.92). There was no significant difference in postoperative respiratory tract infection, anastomotic leak or wound complications between the groups (p=0.2, p=1.0 and p=0.5 respectively). The RSC group had a higher incidence of ileus than the EA group (4/24 vs 2/85, p=0.026). However, the numbers were too small to draw a reliable conclusion. CONCLUSIONS The use of ultrasonography guided RSCs has demonstrated effective postoperative analgesia equivalent to EA with the potential benefits of a reduced incidence of hypotension. A prospective randomised trial is now underway to compare RSC and EA in open abdominal and pelvic surgery.
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Affiliation(s)
- A R Godden
- Royal Devon and Exeter Hospital NHS Foundation Trust, UK
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The use of "spin" in laparoscopic lower GI surgical trials with nonsignificant results: an assessment of reporting and interpretation of the primary outcomes. Dis Colon Rectum 2013; 56:1388-94. [PMID: 24201393 DOI: 10.1097/01.dcr.0000436466.50341.c5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Spin has been defined as "specific reporting that could distort the interpretation of results and mislead readers." OBJECTIVE The purpose of this study was to identify how frequently, and to what extent, "spin" occurs in laparoscopic lower GI surgical trials with nonsignificant results. DATA SOURCES Publications were referenced in MEDLINE and EMBASE (1992-2012). STUDY SELECTION Randomized controlled trials comparing laparoscopic with open surgical technique in lower GI surgery were sought. Trials were included if a nonsignificant (p > 0.05) result of the primary outcome(s) occurred. INTERVENTION The laparoscopic versus open technique in lower GI surgery was studied. MAIN OUTCOME MEASURES Trials were assessed for frequency, strategy, and extent of "spin," as previously defined. RESULTS Fifty-eight trials met the inclusion criteria. Sixty-six percent of these trials had evidence of "spin." In general, authors used significant results only (one of multiple primary outcomes, secondary outcomes, or subgroup analyses) (43%) or interpreted nonsignificance as equivalence (43%). Trials with spin were more likely to recommend the laparoscopic approach over the open technique (p < 0.001), were less likely to call for further trials (p = 0.003), and were less likely to acknowledge the nonsignificant differences (p < 0.001). Inadequate randomization was associated with decreased odds of spin (p = 0.03), as was an intent-to-treat analysis (p < 0.0001), whereas inadequate allocation concealment (p = 0.06) was weakly associated with a decrease in spin. No other a priori candidate risk factors were associated with the presence of spin. LIMITATIONS Funding source was rarely described, so the association between industry funding and spin could not be assessed. CONCLUSION The distortion of nonsignificant results in laparoscopic trials was highly prevalent in this review. Readers of trials with nonsignificant results should be cautious of the authors' interpretations. Editors, reviewers, and publishers should ensure that author's conclusions correspond to the study's results and design.
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van de Velde CJH, Boelens PG, Tanis PJ, Espin E, Mroczkowski P, Naredi P, Pahlman L, Ortiz H, Rutten HJ, Breugom AJ, Smith JJ, Wibe A, Wiggers T, Valentini V. Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery. Eur J Surg Oncol 2013; 40:454-68. [PMID: 24268926 DOI: 10.1016/j.ejso.2013.10.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/23/2013] [Indexed: 12/12/2022] Open
Abstract
The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?
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Affiliation(s)
- C J H van de Velde
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P G Boelens
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - P J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E Espin
- Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - P Mroczkowski
- Department of General, Visceral and Vascular Surgery/An-Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke University of Magdeburg, Germany
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Pahlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - H Ortiz
- Department of Surgery, Public University of Navarra, Spain
| | - H J Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A J Breugom
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - J J Smith
- Department of Colorectal Surgery, West Middlesex University Hospital, Isleworth, UK
| | - A Wibe
- Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - T Wiggers
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - V Valentini
- Unviersita Cattolica S. Cuore, Radioterapia 1, Largo A. Gemelli, 8, 00168 Rome, Italy
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Godden AR, Marshall MJ, Grice AS, Daniels IR. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. Ann R Coll Surg Engl 2013; 95:591-4. [PMID: 24165343 PMCID: PMC4311537 DOI: 10.1308/rcsann.2013.95.8.591] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Epidural anaesthesia (EA) has been the accepted standard for postoperative analgesia in open abdominal surgery. However, it is not without significant risk. This study aimed to audit the effect of EA and ultrasonography placed rectus sheath catheters (RSCs) on analgesia as well as the incidence of postoperative complications following open colorectal cancer surgery. METHODS A three-year retrospective case note review was undertaken of all patients undergoing open colorectal cancer surgery at the Royal Devon and Exeter Hospital NHS Foundation Trust who received either EA or RSC for postoperative analgesia under the care of the senior authors. A single surgeon and single anaesthetist were practitioners. RESULTS The case notes of 120 patients were reviewed retrospectively: 85 patients had EA and 24 RSC while 11 patients were excluded from the study. The EA group experienced a significantly higher incidence of hypotension (systolic blood pressure <130 mmHg) than the RSC group on the first postoperative day (p=0.0001). There was no significant difference in pain score or opiate sparing properties between the groups (p=0.92). There was no significant difference in postoperative respiratory tract infection, anastomotic leak or wound complications between the groups (p=0.2, p=1.0 and p=0.5 respectively). The RSC group had a higher incidence of ileus than the EA group (4/24 vs 2/85, p=0.026). However, the numbers were too small to draw a reliable conclusion. CONCLUSIONS The use of ultrasonography guided RSCs has demonstrated effective postoperative analgesia equivalent to EA with the potential benefits of a reduced incidence of hypotension. A prospective randomised trial is now underway to compare RSC and EA in open abdominal and pelvic surgery.
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Affiliation(s)
- AR Godden
- Royal Devon and Exeter Hospital NHS Foundation Trust,UK
| | - MJ Marshall
- Royal Devon and Exeter Hospital NHS Foundation Trust,UK
| | - AS Grice
- Royal Devon and Exeter Hospital NHS Foundation Trust,UK
| | - IR Daniels
- Royal Devon and Exeter Hospital NHS Foundation Trust,UK
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Intravenous lidocaine for post-operative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial. Tech Coloproctol 2013; 18:373-80. [PMID: 24030782 PMCID: PMC3962581 DOI: 10.1007/s10151-013-1065-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 08/19/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Perioperative intravenous (IV) infusion of lidocaine has been shown to decrease post-operative pain, shorten time to return of bowel function, and reduce the length of hospital stay. This randomized, prospective, double-blinded, placebo-controlled clinical trial evaluated the impact of IV lidocaine on the quality of post-operative analgesia and other outcomes after hand-assisted laparoscopic colon surgery. METHODS Sixty four patients with colon cancer scheduled for elective colon resection were involved in this study. Patients were randomized to receive either lidocaine infusion [lidocaine group (LG)] or normal 0.9 % saline infusion [placebo group (PG)] for a period of 24 h. Anaesthetic and surgical techniques were standardized. Twenty-four-hour post-operative analgesia in the recovery area was maintained by continuous infusion of 0.1 μg/kg/h fentanyl. The primary outcome of the study was post-operative pain control. Pain was assessed using visual analogue scale (VAS) scores at 2, 4, 8, 12, and 24 h after surgery. Patients with a VAS score >3 were treated with ketorolac 30 mg as needed. Secondary outcomes included time to resumption of bowel function and length of hospital stay. Data in the two groups were compared using the two-tailed Student's t test. All statistical tests were two-tailed at a significance level of 0.05. RESULTS Demographic characteristics and clinical features of both groups were similar. Intensity of pain at rest in LG compared with PG was significantly lower during the first 24 h post-operatively. LG patients reported significantly less pain during movements at 2-, 12-, and 24-h post-surgery than PG patients. The study showed that ketorolac consumption was significantly higher in PG: mean ketorolac consumption in LG was 43.77 ± 13.86 mg and in PG 51.67 ± 13.16 mg (p = 0.047). Compared with placebo, lidocaine infusion produced a 32 % reduction in time to the first drink (Cohen's d = 3.85), 16 % reduction in time to the first full diet (Cohen's d = 3.35), and 18 % reduction in time to the first bowel movement (Cohen's d = 2.30). Patients who received lidocaine stayed in hospital 1.2 days less than patients who received placebo (p < 0.01, Cohen's d = 0.72). There were no significant differences in surgery-related complications between the two groups. CONCLUSIONS Perioperative continuous IV lidocaine infusion has a beneficial effect as regards post-operative pain, restoration of bowel function, and length of hospital stay in patients who have undergone hand-assisted laparoscopic colon surgery.
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Abstract
Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.
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Ding J, Liao GQ, Xia Y, Zhang ZM, Liu S, Yan ZS. Laparoscopic versus open right hemicolectomy for colon cancer: a meta-analysis. J Laparoendosc Adv Surg Tech A 2013; 23:8-16. [PMID: 23317438 DOI: 10.1089/lap.2012.0274] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This meta-analysis was designed to assess the feasibility and safety of laparoscopic right hemicolectomy for colon cancer. RESEARCH DESIGN A systematic search of the MEDLINE, EMBASE, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction. Publications that compared laparoscopic right hemicolectomy and open right hemicolectomy for treatment of colon cancer in the past 20 years were collected for review. The primary outcomes used for meta-analysis were operating time, blood loss, number of harvested lymph nodes, time to first flatus, postoperative hospital stay, postoperative complications, mortality, and rate of recurrence. RESULTS Twelve studies that included 1057 patients were examined. Of these patients, 475 and 582 had undergone laparoscopic right hemicolectomy and open right hemicolectomy, respectively. There were significant reductions in blood loss, time to first flatus, postoperative hospital stay, and rate of wound but a operating time for laparoscopic right hemicolectomy compared with open right hemicolectomy. Other outcome variables such as number of harvested lymph nodes, postoperative complications except wound infection, mortality, and rate of recurrence were not found to be statistically significant for either group. CONCLUSIONS Compared with open right hemicolectomy, laparoscopic right hemicolectomy has the advantages of minimal invasion, faster recovery, and a lower rate of wound infection, and it can achieve the same degree of radicality and short-term prognosis as open right hemicolectomy. The drawback is that the operative time is longer.
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Affiliation(s)
- Jie Ding
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China
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35
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Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum 2012; 55:1300-10. [PMID: 23135590 DOI: 10.1097/dcr.0b013e31826ab4dd] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available. OBJECTIVE The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice. DATA SOURCES Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed. STUDY SELECTION Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected. INTERVENTION No interventions were performed. MAIN OUTCOME MEASURES Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process. RESULTS Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed. LIMITATIONS The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve CONCLUSIONS This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.
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Dowson HM, Gage H, Jackson D, Qiao Y, Williams P, Rockall TA. Laparoscopic and open colorectal surgery: a prospective cost analysis. Colorectal Dis 2012; 14:1424-30. [PMID: 22340515 DOI: 10.1111/j.1463-1318.2012.02988.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery. METHOD Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared. RESULTS In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant). CONCLUSION The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.
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Affiliation(s)
- H M Dowson
- Minimal Access Therapy Training Unit, Postgraduate Medical School, University of Surrey, Guildford, UK
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Alasari S, Min BS. Robotic colorectal surgery: a systematic review. ISRN SURGERY 2012; 2012:293894. [PMID: 22655207 PMCID: PMC3359666 DOI: 10.5402/2012/293894] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 01/10/2012] [Indexed: 01/05/2023]
Abstract
Aim. Robotic colorectal surgery may be a way to overcome the limitations of laparoscopic surgery. It is an emerging field; so, we aim in this paper to provide a comprehensive and data analysis of the available literature on the use of robotic technology in colorectal surgery. Method. A comprehensive systematic search of electronic databases was completed for the period from 2000 to 2011. Studies reporting outcomes of robotic colorectal surgery were identified and analyzed. Results. 41 studies (21 case series, 2 case controls, 13 comparative studies 1 prospective comparative, 1 randomized trial, 3 retrospective analyses) were reviewed. A total of 1681 patients are included in this paper; all of them use Da Vinci except 2 who use Zeus. Short-term outcome has been evaluated with 0 mortality and191 total major and minor complications. Pathological results were not analyzed in all studies and only 20 out of 41 provide data about the pathological results. Conclusion. Robotic surgery is safe and feasible option in colorectal surgery and a promising field; however, further prospective randomized studies are required to better define its role.
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Affiliation(s)
- Sami Alasari
- Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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McArthur DR, Sharples A, Ghallab M, Dawson R, Lengyel AJ. Laparoscopic fellowship training can deliver a competent laparoscopic surgeon and trainer. Colorectal Dis 2012; 14:497-501. [PMID: 21689333 DOI: 10.1111/j.1463-1318.2011.02653.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study investigated whether experience gained during a UK laparoscopic colorectal fellowship enabled the fellow subsequently to train consultant colleagues in laparoscopic surgery. METHOD In one unit a newly appointed post-laparoscopic fellowship consultant (PFC) mentored his other two colleagues. Prospectively collected data regarding surgical outcome were compared with those of the year preceding the PFC appointment. RESULTS In the preceding year 18.5% of 260 resections were attempted laparoscopically. This increased to 92.6% (of 270) in the year after (P < 0.0001). Respective conversion rates were 4.2% and 8.4% (P = 0.5524). In the first 6 months after PFC appointment, mentored consultants performed 23 supervised cases. In the second 6 months they carried out 58 procedures independently and trainees performed 38 supervised cases. There was no significant difference in anastomotic leakage and readmission and 30-day mortality rates between the pre- and post-PFC periods. CONCLUSION A laparoscopic fellowship enables the PFC to mentor consultant colleagues safely and effectively.
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Affiliation(s)
- D R McArthur
- Department of Colorectal Surgery, University Hospital North Staffordshire NHS Trust, Stoke-on-Trent, UK.
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Memon S, Heriot AG, Murphy DG, Bressel M, Lynch AC. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol 2012; 19:2095-101. [PMID: 22350601 DOI: 10.1245/s10434-012-2270-1] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery. METHODS A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths. RESULTS Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P=0.03; 95% confidence interval 1-12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P=NS). CONCLUSIONS Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.
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Affiliation(s)
- Sameer Memon
- Department of Colorectal Surgery, Division of Cancer Surgery, Peter MacCallum Cancer Centre, East Melbourne, Australia
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Hildebrand DR, Binnie NR, Aly EH. Is routine blood cross-matching necessary in elective laparoscopic colorectal surgery? Int J Surg 2012; 10:92-5. [PMID: 22246166 DOI: 10.1016/j.ijsu.2011.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 11/23/2011] [Accepted: 12/22/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Routine pre-operative cross-matching of two units of packed red cells (PRC) is current practice in most hospitals for patients undergoing elective laparoscopic colorectal surgery (LCS). AIMS To determine the usage of PRC in patients undergoing elective LCS & its cost implications. METHODS Retrospective analysis of 116 consecutive laparoscopic colorectal resections under the care of 2 consultant surgeons. RESULTS Surgical procedures were anterior resection (31.9%; n = 37), right hemicolectomy (22.4%; n = 26), sigmoid colectomy (22.4%; n-26), subtotal colectomy (7.8%; n = 9), APR (4.3%; n = 5), panproctocolectomy (3.4%; n = 4), completion proctectomy (1.7%, n = 2), left hemicolectomy (0.9%, n = 1), total colectomy (0.9%; n = 1) & resection rectopexy (0.9%; n = 1). The median age was 65 years, 58% female. The median pre-operative haemoglobin was 131 g/L, median blood loss 100 ml and median post-operative haemoglobin 111.5 g/L. Eleven cases were converted. Three patients required perioperative blood transfusion, 2 of whom underwent open conversion. The cost of carrying out a group & save (G&S) in our hospital is £40.60 excluding laboratory staff labour cost. A 2 unit cross-match costs £294.60. There is potential for substantial cost savings with change of practice to G&S only. CONCLUSION G&S is sufficient to allow safe & cost-effective operative practice in laparoscopic colorectal surgery.
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Affiliation(s)
- Diane R Hildebrand
- Laparoscopic Colorectal Surgery and Training Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
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Newman CM, Arnold SJ, Coull DB, Linn TY, Moran BJ, Gudgeon AM, Cecil TD. The majority of colorectal resections require an open approach, even in units with a special interest in laparoscopic surgery. Colorectal Dis 2012; 14:29-34; discussion 42-3. [PMID: 21070568 DOI: 10.1111/j.1463-1318.2010.02504.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Proponents suggest that laparoscopic colorectal resection might be achievable in up to 90% of cases, while keeping conversion rates below 10%. This unselected prospective case series reports on the proportion of patients having a completed laparoscopic colorectal resection in two units where laparoscopic colorectal practice is well established and readily available. METHOD All patients undergoing elective and emergency colorectal resection during a 6-month period were identified. The underlying pathology and the surgical approach (laparoscopic or open) were recorded. The contraindications to laparoscopic resection were also documented. The need and rationale for conversion to an open approach were recorded. RESULTS In total, 205 consecutive patients (160 elective and 45 emergency procedures) underwent colorectal resection for malignancy [117 (57%) patients] and benign pathology [88 (43%) patients]. Laparoscopic resection was attempted in 127/205 (62%) patients and 31/127 (24%) of these were converted to open surgery. The main reasons for not attempting laparoscopic resection were locally advanced disease and emergency surgery. The commonest reasons for conversion were advanced disease and to allow completion of rectal dissection and/or cross-stapling of the rectum. CONCLUSION Despite a special interest in laparoscopic colorectal surgery of the two colorectal units who provided the data for this study, fewer than half (96/205; 47%) of the patients in this consecutive unselected series who were undergoing major colorectal resection had the procedure completed laparoscopically.
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Affiliation(s)
- C M Newman
- Department of Colorectal Surgery, North Hampshire Hospital, Basingstoke, Hampshire, UK.
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Richardson G, Whiteley I. A comparison of nurses' perceptions of elective laparoscopic or elective open colorectal resections. Int J Nurs Pract 2011; 17:621-7. [PMID: 22103829 DOI: 10.1111/j.1440-172x.2011.01979.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to develop an instrument to measure the perceived benefits nurses observe in the recovery of patients who have undergone elective laparoscopic colorectal resections vs. traditional open elective colorectal resections. Secondly, to determine if there are perceived differences in the intensity of nursing required to care for these patients. A twenty-three-point questionnaire was developed and distributed to 23 colorectal nurses working in a single tertiary referral hospital. There was an 83.6% response rate. The findings demonstrate that the participants believe there are significantly better outcomes for the laparoscopic patients in the postoperative period. These benefits include more rapid resumption of independence, decreased pain and fewer complications. The nurses also perceived less time and effort was required when caring for these patients.
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Affiliation(s)
- Gillian Richardson
- Ground Floor West, Concord Repatriation Hospital, Concord, New South Wales, Australia.
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Fichera A, Zoccali M, Felice C, Rubin DT. Total abdominal colectomy for refractory ulcerative colitis. Surgical treatment in evolution. J Gastrointest Surg 2011; 15:1909-16. [PMID: 21909842 DOI: 10.1007/s11605-011-1666-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/09/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Total abdominal colectomy is the procedure of choice for debilitated patients with acute, medical refractory ulcerative colitis in our practice. A laparoscopic approach has been previously shown to be safe and effective, and has become our preferred strategy. This study illustrates the laparoscopic evolution towards a truly minimally invasive approach comparing three phases of a single colorectal surgeon experience. MATERIAL AND METHODS In May 2010 single incision laparoscopy was introduced in our practice and has become our preferred approach. Ten consecutive ulcerative colitis patients were case matched and compared with 10 previous laparoscopic-assisted (Feb 2003-Jan 2007) and 10 hand-assisted (Feb 2006-Apr 2010) total abdominal colectomies. Patient, disease and surgery-related factors were analyzed and short-term outcomes were compared. RESULTS Given the study design, there were no differences in demographics, smoking history, disease duration and severity, nutritional and inflammatory parameters, and indication for surgery between groups. Single incision patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p = 0.016). In the single incision group we noticed significantly shorter duration of surgery (p < 0.001) and faster resumption of solid diet (p = 0.019) compared to the other groups. Other short-term outcomes did not differ between groups. CONCLUSION Single incision laparoscopy offers a safe alternative to other laparoscopic approaches. Despite the higher technical complexity, the duration of surgery is shorter with faster resumption of oral intake. Studies with larger sample size and longer follow-up will be required to confirm the benefits of this approach.
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Affiliation(s)
- Alessandro Fichera
- Department of Surgery, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Kahokehr A, Robertson P, Sammour T, Soop M, Hill AG. Perioperative care: a survey of New Zealand and Australian colorectal surgeons. Colorectal Dis 2011; 13:1308-13. [PMID: 20958906 DOI: 10.1111/j.1463-1318.2010.02453.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM Recent surveys in Europe and North America have demonstrated significant challenges in the implementation of evidence-based surgical practice. METHOD A survey of New Zealand and Australian colorectal surgeons was conducted to help understand current practice and perceived barriers to interventions in this region. Questions were based around elective colorectal resection care. RESULTS There were 152 eligible participants identified. Over a 60-day period, 82 (54%) surgeons responded but only 76 (50%) of the questionnaires were complete; they were used for data analysis. The majority of surgeons indicated a preference for laparoscopic techniques. Barriers to laparoscopy include lack of operating time, lack of adequate training and institutional pressures. Only 28 (37%) indicated that they cared for patients in a formalized enhanced recovery programme (ERAS). Barriers to implementing ERAS included lack of support from institutions and other specialities. Routine oral 'mechanical' bowel preparation for colon and rectal resection was preferred by 28% and 63%, respectively. Drainage after routine colon and rectal resection was not used by 62 (83%) and 39 (53%). Prophylactic nasogastric intubation afterwards was not used by 66 (87%) responders. The preferred mode of analgesia was patient-controlled opioid analgesia (PCA) for 52%. A 'restrictive' intravenous fluid therapy was preferred by 34 (49%) while 33 (48%) preferred no fluid restriction. A prolonged 'nil by mouth' status was preferred by 28%. CONCLUSION There appears to be a high rate of evidence in agreement with some interventions but not others. The systemic barriers to implementing evidence-based perioperative care need attention.
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Affiliation(s)
- A Kahokehr
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand.
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Good DW, O'Riordan JM, Moran D, Keane FB, Eguare E, O'Riordain DS, Neary PC. Laparoscopic surgery for rectal cancer: a single-centre experience of 120 cases. Int J Colorectal Dis 2011; 26:1309-15. [PMID: 21701808 DOI: 10.1007/s00384-011-1261-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION For colorectal surgeons, laparoscopic rectal cancer surgery poses a new challenge. The defence of the questionable oncological safety tempered by the impracticality of the long learning curve is rapidly fading. As a unit specialising in minimally invasive surgery, we have routinely undertaken rectal cancer surgery laparoscopically since 2005. METHODS Patients undergoing surgery for rectal cancer between June 2005 and February 2010 were retrospectively reviewed from a prospectively maintained colorectal cancer database. RESULTS One hundred and thirty patients underwent surgery for rectal cancer during the study period. One hundred and twenty patients had a laparoscopic resection, six were converted to open (conversion rate 5%) and 10 had a planned primary open procedure. Fifty four were low rectal tumours and 76 were upper rectal tumours. One hundred and thirteen patients had an anterior resection (87%), 17 patients an abdomino-perineal resection (13%) and 62 of the 130 patients (47.6%) had neoadjuvant radiotherapy. The median lymph node retrieval rate was 12 (9-14), five patients (3.8%) had a positive circumferential margin and the clinical anastomotic leak rate was 3.8% (n = 5 patients). There was no significant difference in the stated parameters for neoadjuvant versus non-neoadjuvant patients and for upper versus lower rectal tumours. Ninety three percent of mesorectal excision specimens were complete on pathological assessment. CONCLUSIONS During the study period, 92% of rectal cancers underwent a laparoscopic resection with low rates of morbidity and acceptable short-term oncological outcomes. This data supports the view that laparoscopic surgery for rectal cancer can be safely delivered in mid-volume centres by surgeons who have completed the learning curve for laparoscopic colorectal surgery.
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Affiliation(s)
- Daniel W Good
- Minimally Invasive Surgical Unit, Division of Colorectal Surgery, Adelaide and Meath Incorporating the National Childrens Hospital, Tallaght, Dublin 24, Ireland.
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Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis. Surg Endosc 2011; 26:862-8. [PMID: 21959686 DOI: 10.1007/s00464-011-1925-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 06/02/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND A three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC). METHODS Nine consecutive patients with medically refractory UC underwent a single-incision laparoscopic TAC between May and October 2010. All patients were on aggressive medical therapy with corticosteroids or immunosuppressors and were selected for this approach on the basis of their body habitus and the absence of relevant comorbidities. The whole operation was performed through a single access to the abdominal cavity, placed at the ostomy site marked preoperatively. RESULTS Mean operating time was 142 ± 23 min, with an estimate blood loss of 108 ± 125 ml. No intraoperative complications or conversions to conventional laparoscopy or open surgery occurred. In all cases the postoperative course was uneventful. The return of bowel function was observed on postoperative day 1.7 ± 0.7, and patients could tolerate a solid diet on postoperative day 3 ± 0.5. The mean postoperative length of stay was 5.2 ± 1.3 days. CONCLUSIONS In our experience, a single-incision laparoscopic approach to total abdominal colectomy for refractory ulcerative colitis has been shown to be safe and feasible. Initial results suggest that this technique can lead to improvements in short-term outcomes in selected patients.
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Chambers WM, Bicsak M, Lamparelli M, Dixon AR. Single-incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis. Colorectal Dis 2011; 13:393-8. [PMID: 20002691 DOI: 10.1111/j.1463-1318.2009.02158.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM Single-incision (or port) laparoscopic surgery (SILS) has recently emerged as a method to improve morbidity and cosmetic benefit of conventional laparoscopic surgery. The literature contains two reports of SILS right hemicolectomy, and we report our experience of this technique. METHOD Seven consecutive, unselected patients underwent SILS retrocaecal appendicectomy, right hemicolectomy, extended right hemicolectomy, colectomy with ileorectal anastomosis, proctocolectomy, anterior resection and restorative proctocolectomy/ileoanal pouch using a single Triport (Olympus Keymed, Southend, UK), conventional instrumentation and nerve block analgesia. Three had undergone previous surgery, two had cancer and two were immunosuppressed. RESULTS Umbilical, right- and left-iliac fossa SILS was feasible using conventional instruments. Operative time ranged between 23 and 195 min (median 48 min). Four patients tolerated normal diet within 6 h (12-16 h for the remainder). Only one patient required postoperative enteral morphine (10 mg × 4). Discharge occurred between 8 and 90 h (median 16 h) of surgery. A secondary haemorrhage from the ileorectal anastomosis was managed conservatively. CONCLUSION SILS colorectal resection is feasible and safe when performed by an experienced laparoscopic surgeon and theatre team. It may have advantages over conventional laparoscopic surgery in terms of reduced pain, lower cost, faster recovery and cosmesis.
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Shah PR, Gupta V, Haray PN. A unique approach to quantifying the changing workload and case mix in laparoscopic colorectal surgery. Colorectal Dis 2011; 13:267-71. [PMID: 19930148 DOI: 10.1111/j.1463-1318.2009.02143.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic colorectal surgery includes a range of operations with differing technical difficulty, and traditional parameters, such as conversion and complication rates, may not be sensitive enough to assess the complexity of these procedures. This study aims to define a reproducible and reliable tool for quantifying the total workload and the complexity of the case mix. METHOD This is a review of a single surgeon's 10-year experience. The intermediate equivalent value scoring system was used to code complexity of cases. To assess changes in the workload and case mix, the period has been divided into five phases. RESULTS Three hundred and forty-nine laparoscopic operations were performed, of which there were 264 (75.6%) resections. The overall conversion rate was 17.8%, with progressive improvement over the phases. Complex major operation (CMO), as defined in the British United Provident Association (BUPA) schedule of procedures, accounted for 35% of the workload. In spite of similar numbers of cases in each phase, there was a steady increase in the workload score, correlating with the increasing complexity of the case mix. There was no significant difference in the conversion and complications rates between CMO and non-CMO. The paradoxical increase in the mean operating time with increasing experience corresponded to the progressive increase in the workload score, reflecting the increasing complexity of the case mix. CONCLUSION This article establishes a reliable and reproducible tool for quantifying the total laparoscopic colorectal workload of an individual surgeon or of an entire department, while at the same time providing a measure of the complexity of the case mix.
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Affiliation(s)
- P R Shah
- Cwm Taf NHS Trust, Prince Charles Hospital, Merthyr Tydfil, Wales School of Health, Science and Sports, University of Glamorgan, Pontypridd, Wales, UK
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Dalton SJ, Ghosh A, Greenslade GL, Dixon AR. Laparoscopic colorectal surgery - why would you not want to have it and, more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomoses. Colorectal Dis 2011; 13:144-9. [PMID: 19888953 DOI: 10.1111/j.1463-1318.2009.02101.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM We analysed the outcome of a consecutive series of 500 unselected patients who underwent elective laparoscopic colorectal resection with anastomosis (ELCRA) under the care of a single surgeon. METHOD A prospectively collected electronic database of all laparoscopic procedures conducted from April 2001 to September 2008 was analysed. RESULTS A total of 500 ELCRAs were performed [230 male and 270 female patients; mean age 65.6 years (range 19-93 years; American Society of Anesthesiologists grade I (103), II (246), III (145) and IV (6)]. Of these, 217 patients underwent high anterior resection. A total of 131 total mesorectal excisions (55 covering ileostomies), 152 right/extended right resections and 240 operations were performed by trainees under supervision. The indications for surgery included cancer (340), diverticular disease (96), Crohn's disease (40) and polyps (24). Mean operating time was 115 min (range 35-550 min). There were eight (1.6%) conversions. The mean length of hospital stay was 5.2 days (median 4 days). A total of 93 (18.6%) patients had an inpatient complication, including ileus (22), wound infection (14), anastomotic leakage (12), enterotomy (2), 'off-screen' enterotomy (2), abscess (3), ureteric injury (1), cardiac arrhythmia (12), myocardial infarction (5), pulmonary embolus (4), pneumonia (1), Clostridium difficile (3) and retention of urine (9). There were 20 (4%) readmissions for complications, including ileus (4), urinary retention (3), abscess formation (2) and leakage (2). The 30-day mortality was nine of 500 (1.8%) following anastomotic leakage (3), duodenal enterotomy (1), bleeding duodenal ulcer (1), C. difficile infection (1) and cardiac complications (3). CONCLUSION This unselected cohort of patients (the largest single surgeon series in the UK) demonstrates that in trained hands low conversion and complication rates can be consistently achieved.
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Affiliation(s)
- S J Dalton
- Department of Colorectal Surgery, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK
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