Laparoscopic colectomy: trends in implementation in Canada and globally

The impact of robotic rectal cancer surgery at a Canadian regional cancer centre: a retrospective cohort study

BACKGROUND

Although robotic surgery has several advantages over other minimally invasive surgery (MIS) techniques for rectal cancer surgery, the uptake in Canada has been limited owing to a perceived increase in cost and lack of training. The objective of this study was to determine the impact of access to robotic surgery in a Canadian setting.

METHODS

We conducted a retrospective cohort study involving consecutive adults undergoing surgical resection for rectal cancer between 2017 and 2020. The primary exposure was access to robotic surgery. Outcomes included MIS utilization, short-term outcomes, total cost of care, and quality of surgical resection. We completed univariate and multivariate analyses.

RESULTS

We included 171 individuals in this cohort study (85 in the prerobotic period and 86 in the robotic period). The 2 groups had similar baseline characteristics. A higher proportion of individuals underwent successful MIS in the robotic phase (86% v. 46%, p < 0.001). Other benefits included a shorter mean length of hospital stay (5.1 d v. 9.2 d, p < 0.001). The quality of surgical resection was similar between groups. The total cost of care was $16 746 in the robotic period and $18 808 in the prerobotic period (mean difference -$1262, 95% confidence interval -$4308 to $1783; p = 0.4).

CONCLUSION

Access to robotic rectal cancer surgery increased successful completion of MIS and shortened hospital stay, with a similar total cost of care. Robotic rectal cancer surgery can enhance patient outcomes in the Canadian setting.

Postoperative outcomes of right hemicolectomy for cancer in 11 countries of Latin America: A multicentre retrospective study

AIM

There is scant evidence regarding surgical outcomes of patients with colon cancer in Latin America. The aim of this work was to compare perioperative (30 day) outcomes of patients undergoing surgery for right colon cancer in Latin America based on centre volume.

METHOD

This is a multi-institutional retrospective cohort study. Individuals operated on for right colon cancer with curative intent in an urgent or elective setting between 2016 and 2021 were eligible for inclusion in the study. Patients were divided into two groups according to whether they were operated on in low-volume or high-volume centres (defined as more than 30 cases/year).

RESULTS

A total of 2676 patients from 46 hospitals in 11 countries of Latin America were included, with 389 (14.5%) in the low-volume group. The median age was 67.37 years. The high-volume group presented higher rates of laparoscopic procedures (56.8 vs. 35.7%, p < 0.001, OR 2.36), with lower conversion rates, fewer intraoperative complications and a shorter operating time. The high-volume group had a shorter length of hospital stay. The overall complication rate for the whole group was 15.9%, with a lower incidence of these events in the high-volume group (13.7 vs. 28.7%, p < 0.001, OR 0.40). Overall, anastomotic leakage, reoperation and mortality rates were 5.6%, 9.2% and 6.1%, respectively, with differences favouring high-volume centres. On multivariate analysis, low-volume group, history of cardiac disease, emergency surgery, operation performed by a general surgeon, open approach and intraoperative complications were independent predictors of major postoperative complications.

CONCLUSION

This is the first study in Latin America to show better postoperative outcomes at a regional scale when surgery for right colon cancer is performed in high-volume centres. Further studies are needed to validate these data and to identify which of the factors can explain the present results.

The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short term outcomes: A Canadian perspective

BACKGROUND

Robotic surgery for colorectal pathology has gained interest as it can overcome technical challenges and limitations of traditional laparoscopic surgery. A lack of training and costs have been cited as reasons for limiting its use in Canada. The objective of this paper was to assess the impact of robotic surgery on outcomes and costs in a Canadian setting.

METHODS

This is a retrospective study of consecutive patients undergoing left sided colorectal surgery ("Pre-Robotic Phase" n = 145 vs. "Post Robotic Phase" n = 150) and a single tertiary care centre in Ontario, Canada. Utilization and success of minimally invasive surgery (MIS), length of stay, complications and hospital costs were compared. Univariate and Multivariate analysis was used for these comparisons.

RESULTS

Characteristics, diagnosis and type of resection were similar between groups. Robotic Implementation resulted in higher rates of successful MIS (i.e. attempt at MIS without conversion) (85% vs. 47%, P < 0.001), shorter mean length of stay (4.7 days vs. 8.4 days, P < 0.001), and similar mean operative times (3.9 h vs. 3.9 h, P = 0.93). Emergency Department visits were fewer in the Robotic Phase (24% vs. 34%, P = 0.04), with no difference in readmission, anastomotic leak or unplanned reoperation. After robotic implementation, the mean total hospital costs decreased, but this was not statistically significant (-$1453, 95% CI -$3974 to +$1068, P = 0.25). Regression analysis, adjusting for age, gender, obesity, ASA and procedure showed similar findings (Robotic Phase -$657, 95% CI -$3038 to +$1724, vs Pre Robotic Phase [Reference], P = 0.59).

INTERPRETATION

Implementation of a robotic colorectal surgery program in a Canadian tertiary care centre showed improved clinical outcomes, without a significant increase in the cost of care. Although this study is from a single institution, we have demonstrated that robotic colorectal surgery is feasible and can be cost effective in the right setting.

Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites

BACKGROUND

Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors.

OBJECTIVE

The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use.

DESIGN

This was a population-based retrospective analysis from April 2008 to March 2015.

SETTINGS

All Canadian provinces (excluding Quebec) were included.

PATIENTS

The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer.

MAIN OUTCOME MEASURES

The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center.

RESULTS

A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001).

LIMITATIONS

Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias.

CONCLUSIONS

Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595.

VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES

ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis

AIM

Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery.

METHODS

Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO.

RESULTS

Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar.

CONCLUSIONS

Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.

Enthusiasm, Opinion Leaders, Comparative Advantage, and the Uptake Of Laparoscopic Resection For Colorectal Cancer Liver Metastases in Ontario, Canada: A Population-Based Cohort Study

BACKGROUND

Numerous factors likely influence adoption of surgical innovations in large regions. We considered the role of comparative advantage, surgeon enthusiasm, and opinion leaders on uptake of minimally invasive liver resection (MILR) for colorectal cancer (CRC) metastases in Ontario.

METHODS

We used administrative data for patients undergoing liver resection for CRC metastases from years 2006-2015. Fourteen regions were divided into three groups based on overall rate of MILR for CRC metastases. Outcomes included postoperative complications, length of hospital stay (LOS), operative mortality, and 1-year survival. We evaluated uptake of MILR among groups and within groups between opinion leader and nonopinion leader surgeons.

RESULTS

There were 2675 patients in the low-rate (n = 937), medium-rate (n = 919), and high-rate (n = 819) groups. In these same groups, the number of opinion leader surgeons was six, five, and six. Patient outcomes were similar among groups, except in the low-rate group LOS was 1 day greater (7 vs. 6 and 6; p = 0.017). The rate of MILR for CRC metastases did not change significantly among opinion leaders in any group. This rate among nonopinion leader surgeons was steady and low in the low-rate group (1.7-8.0%, p = 0.80) and increased in the mid-rate group (2.4-31.8%, p = 0.0026) and in the high-rate group (7.7-40.9%, p < 0.001).

CONCLUSIONS

Greater use of MILR was associated with a 1-day shorter LOS. Relative enthusiasm for MILR for CRC metastases among a small number of opinion leader surgeons likely facilitated or dampened uptake of this complex innovation.

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis

BACKGROUND

Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

MATERIALS AND METHODS

The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI.

RESULTS

Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P < 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P < 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m² increase; 95% CI 1.20-1.27; P < 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P < 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P < 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P < 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus ≤ 2; 95% CI 2.16-2.78; P < 0.01), chemotherapy within 90 d (AOR = 1.57; 95% CI 1.33-1.84; P < 0.01), and steroid use (AOR = 1.46; 95% CI 1.29-1.65; P < 0.01). Receipt of an oral antibiotic prep preoperatively was the strongest factor associated with SSI.

CONCLUSIONS

SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity.