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Nasser K, Jatana S, Switzer NJ, Karmali S, Birch DW, Mocanu V. Predictors and Outcomes Associated with Bariatric Robotic Delivery: An MBSAQIP Analysis of 318,151 Patients. J Clin Med 2024; 13:4196. [PMID: 39064235 PMCID: PMC11278286 DOI: 10.3390/jcm13144196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The adoption of robotic bariatric surgery has increased dramatically over the last decade. While outcomes comparing bariatric and laparoscopic approaches are debated, little is known about patient factors responsible for the growing delivery of robotic surgery. A better understanding of these factors will help guide the planning of bariatric delivery and resource allocation. Methods: Data were extracted from the MBSAQIP registry from 2020 to 2021. The patient population was organized into primary robot-assisted sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) versus those who underwent laparoscopic procedures. Bivariate analysis and multivariable logistic regression modeling were conducted to characterize cohort differences and identify independent patient predictors of robotic selection. Results: Of 318,151, 65,951 (20.7%) underwent robot-assisted surgery. Patients undergoing robotic procedures were older (43.4 ± 11.8 vs. 43.1 ± 11.8; p < 0.001) and had higher body mass index (BMI; 45.4 ± 7.9 vs. 45.0 ± 7.6; p < 0.001). Robotic cases had higher rates of medical comorbidities, including sleep apnea, hyperlipidemia, gastroesophageal reflux disease (GERD), and diabetes mellitus. Robotic cases were more likely to undergo RYGB (27.4% vs. 26.4%; p < 0.001). Robotic patients had higher rates of numerous complications, including bleed, reoperation, and reintervention, resulting in higher serious complication rates on multivariate analysis. Independent predictors of robotic selection included increased BMI (aOR 1.02), female sex (aOR 1.04), GERD (aOR 1.12), metabolic dysfunction, RYGB (aOR 1.08), black racial status (aOR 1.11), and lower albumin (aOR 0.84). Conclusions: After adjusting for comorbidities, patients with greater metabolic comorbidities, black racial status, and those undergoing RYGB were more likely to receive robotic surgery. A more comprehensive understanding of patient factors fueling the adoption of robotic delivery, as well as those expected to benefit most, is needed to better guide healthcare resources as the landscape of bariatric surgery continues to evolve.
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Affiliation(s)
- Khadija Nasser
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
| | - Sukhdeep Jatana
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
| | - Noah J. Switzer
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
| | - Daniel W. Birch
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440-112 ST NW, Edmonton, AB T6G 2B7, Canada; (K.N.); (V.M.)
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Fu H, Hillman E, Talluri S, Liang L, Mohammed S, Messer J. Comparison of the perioperative outcomes of using the Firefly system with indocyanine green during robotic-assisted cystectomy with urinary diversion. Int J Urol 2024; 31:646-652. [PMID: 38426591 DOI: 10.1111/iju.15438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Use of indocyanine green (ICG) with near-infrared fluorescence (NIRF) has been demonstrated to be an effective tool for intraoperative assessment of bowel and ureteric vascularity. This study aimed to evaluate the impact of ICG on postsurgical outcomes such as anastomotic bowel leak and uretero-enteric stricture formation during robot-assisted cystectomy (RAC) and intracorporeal urinary diversion (ICUD). METHODS We identified 238 patients who underwent RAC at the University of Louisville between September 2012 and August 2021. Patients were divided into two groups based on the utilization of ICG. Demographic, perioperative outcomes, and rate of anastomotic bowel leak were compared. RESULTS In total, 138 patients were in the ICG group and 100 patients were in the non-ICG group. More intracorporeal urinary diversions and more simple cystectomies were observed in the ICG group (p < 0.001 and p = 0.015, respectively). The ICG group patients initiated an oral diet sooner than the control group (4.9 vs. 7.1 days, p < 0.001). The mean length of stay of the ICG group was shorter than the non-ICG group (8.3 vs. 12.8 days, p < 0.001). The rate of postoperative ileus was not significantly different between cohorts. No patients in the ICG group experienced a bowel leak compared with five patients in the non-ICG group (p = 0.008). CONCLUSIONS In our study, the use of ICG for intraoperative assessment of bowel and ureteric vascularity was associated with earlier bowel recovery and a shorter length of stay. It was also significantly correlated with a lower rate of anastomotic bowel leak.
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Affiliation(s)
- Hangcheng Fu
- Urology Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Emily Hillman
- Urology Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Sriharsha Talluri
- Urology Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Lifan Liang
- Medicine Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Said Mohammed
- Urology Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Jamie Messer
- Urology Department of University of Louisville School of Medicine, Louisville, Kentucky, USA
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Devesa JM, Zbar AP, Pescatori M, Ballestero A. Whither the coloproctologist of the future? Returning to the kindred spirit of the barber-surgeon. Tech Coloproctol 2024; 28:26. [PMID: 38236438 DOI: 10.1007/s10151-023-02894-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- J M Devesa
- Colorectal Unit, Hospital Ruber Internacional, C/La Maso, 38, 28034, Madrid, Spain.
| | - A P Zbar
- Department of Neuroscience and Anatomy, University of Melbourne Australia, Melbourne, Australia
| | - M Pescatori
- Coloproctology Units, Parioli Clinic Rome and Cobellis Clinic, Vallo Della Lucania, Italy
| | - A Ballestero
- Department of Surgery, Ramón y Cajal University Hospital Madrid, Madrid, Spain
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Hayden DM, Korous KM, Brooks E, Tuuhetaufa F, King-Mullins EM, Martin AM, Grimes C, Rogers CR. Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2023; 37:3306-3320. [PMID: 36520224 PMCID: PMC10947550 DOI: 10.1007/s00464-022-09793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.
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Affiliation(s)
- Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin M Korous
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA
| | - Ellen Brooks
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | - Fa Tuuhetaufa
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | | | - Abigail M Martin
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chassidy Grimes
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Charles R Rogers
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA.
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Ishikawa N, Watanabe G, Horikawa T, Seguchi R, Kiuchi R, Tomita S, Ohtsuka T. Robot-Assisted Totally Endoscopic Mitral Valve Plasty and Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:e93-e95. [PMID: 35447120 DOI: 10.1016/j.athoracsur.2022.03.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/16/2022] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
Abstract
We experienced 3 cases of port-access robot-assisted totally endoscopic technique for mitral valve repair and concomitant coronary artery bypass. The right internal mammary artery was harvested, mitral valve was fixed, and the right internal mammary artery to right coronary artery anastomosis was carried out on the arrested heart. The use of cardiac arrest and a V-shaped hook technique facilitated the coronary anastomosis and the da Vinci Firefly test (Intuitive Surgical Inc., Sunnyvale, CA) could confirm patency of the graft.
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Affiliation(s)
- Norihiko Ishikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan.
| | - Go Watanabe
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Takafumi Horikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Ryuta Seguchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Ryuta Kiuchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Shigeyuki Tomita
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Toshiya Ohtsuka
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
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Abstract
Compared with other fields, adoption of robotics in colorectal surgery remains relatively slow. One of the reasons for this is that the expected benefits of robotics, such as greater accuracy, speed, and better patient outcomes, are not born out in evidence comparing use of robotics for colorectal procedures to conventional laparoscopy. But evidence also suggests that outcomes with colorectal robotic procedures depend on the experience of the surgeon, suggesting that a steep learning curve is acting as a barrier to the benefits of robotics being realized. In this paper, we analyze exactly why surgeon skill and proficiency is such a critical factor in colorectal surgery, especially around the most complex procedures associated with cancer. Shortening of the learning curve is crucial for both the adoption of the technique and the efficient use of expert trainers. Looking beyond the basics of training and embracing a new generation of digital learning technologies that facilitate peer-to-peer collaboration and development beyond the confines of individual institutions may be an important contributor to achieve these goals in the future.
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Affiliation(s)
- Nadine Hachach-Haram
- Department of Surgery and Clinical Innovation, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Danilo Miskovic
- Department of Surgery and Clinical Innovation, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
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Unruh KR, Bastawrous AL, Bernier GV, Flum DR, Kumar AS, Moonka R, Thirlby RC, Simianu VV. Evaluating the Regional Uptake of Minimally Invasive Colorectal Surgery: a Report from the Surgical Care Outcomes Assessment Program. J Gastrointest Surg 2021; 25:2387-2397. [PMID: 33206328 DOI: 10.1007/s11605-020-04875-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive surgery (MIS) for colorectal disease has well-known benefits, but many patients undergo open operations. When choosing an MIS approach, robotic technology may have benefits over traditional laparoscopy and is increasingly used. However, the broad adoption of MIS, and specifically robotics, across colorectal operations has not been well described. Our primary hypothesis is that rates of MIS in colorectal surgery are increasing, with different contributions of robotics to abdominal and pelvic colorectal operations. METHODS Rates of MIS colorectal operations are described using a prospective cohort of elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP) from 2011 to 2018. The main outcome was proportion of cases approached using open, laparoscopic, and robotic surgery. Factors associated with increased use of MIS approaches were described. RESULTS Across 21,423 elective colorectal operations, rates for MIS (laparoscopic or robotic surgery) increased from 44% in 2011 to 75% in 2018 (p < 0.001). Approaches for abdominal operations (n = 12,493) changed from 2 to 11% robotic, 43 to 63% laparoscopic, and 56 to 26% open (p < 0.001). Approaches for pelvic operations (n = 8930) changed from 3 to 33% robotic, 40 to 42% laparoscopic, and 57 to 24% open(p < 0.001). These trends were similar for high-(100 + operations/year) and low-volume hospitals and surgeons. CONCLUSIONS At SCOAP hospitals, the majority of elective colorectal operations is now performed minimally invasively. The increase in the MIS approach is primarily driven by laparoscopy in abdominal procedures and robotics in pelvic procedures.
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Affiliation(s)
- Kenley R Unruh
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | | | - Greta V Bernier
- Colon and Rectal Surgery Clinic, University of Washington Medicine-Valley Medical Center, Renton, WA, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Anjali S Kumar
- Department of Medical Education and Clinical Sciences, Washington State University, Spokane, WA, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, 1100 9th Ave, C6-GS, Seattle, WA, 98101, USA.
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Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy. J Robot Surg 2021; 16:655-663. [PMID: 34368911 DOI: 10.1007/s11701-021-01290-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9 min vs laparoscopic group 254.2 min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3 min vs laparoscopic group 14.2 min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9 min, p < 0.001) and for ICA (robotic 31.6 min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.
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Parascandola SA, Horsey ML, Hota S, Paull JO, Graham A, Pudalov N, Smith S, Amdur R, Obias V. The robotic colorectal experience: an outcomes and learning curve analysis of 502 patients. Colorectal Dis 2021; 23:226-236. [PMID: 33048409 DOI: 10.1111/codi.15398] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to present our experience with robotic colorectal surgery since its establishment at our institution in 2009. By examining the outcomes of over 500 patients, our experience provides a basis for assessing the introduction of a robotic platform in a colorectal practice. Specific measures investigated include intraoperative data and postoperative outcomes for all operations using the robotic platform. In addition, for our most commonly performed operations we wished to analyse the learning curve to improve operative proficiency. This is the largest single-surgeon robotic database analysed to date. METHOD A prospectively maintained database of patients who underwent robotic colorectal surgery by a single surgeon at the George Washington University Hospital was retrospectively reviewed. Demographic data and perioperative outcomes were assessed. Additionally, an operating time learning curve analysis was performed. RESULTS Inclusion criteria identified 502 patients who underwent robotic colorectal surgery between October 2009 and December 2018. The most common indications for surgery were diverticulitis (22.9%), colon adenocarcinoma (22.1%) and rectal adenocarcinoma (19.5%). The most common operations were anterior/low anterior resection (33.9%), right hemicolectomy/ileocaecectomy (24.9%) and left hemicolectomy/sigmoidectomy (21.9%). The rate of conversion to open surgery was 4.8%. The most common postoperative complications were wound infection (5.0%), anastomotic leakage (4.0%) and abscess formation (2.8%). The operating time learning curve plateaued at 55-65 cases for anterior and low anterior resection and 35-45 cases for left hemicolectomy and sigmoidectomy. A clear learning curve was not seen in right hemicolectomy. CONCLUSION Robotic-assisted surgery can be performed in a diverse colorectal practice with low rates of conversion and postoperative complications. Plateau performance was achieved after 65 anterior/low anterior resections and 45 left and sigmoid colectomies.
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Affiliation(s)
| | | | - Salini Hota
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Ada Graham
- Department of Colorectal Surgery, George Washington University Hospital, Washington, DC, USA
| | - Natalie Pudalov
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Savannah Smith
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard Amdur
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Vincent Obias
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
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Trends in utilization, conversion rates, and outcomes for minimally invasive approaches to non-metastatic rectal cancer: a national cancer database analysis. Surg Endosc 2020; 35:3154-3165. [PMID: 32601761 DOI: 10.1007/s00464-020-07756-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study examined utilization and conversion rates for robotic and laparoscopic approaches to non-metastatic rectal cancer. Secondary aims were to examine short- and long-term outcomes of patients who underwent conversion to laparotomy from each approach. METHODS The National Cancer Database (NCDB) was reviewed for all cases of non-metastatic adenocarcinoma of the rectum or rectosigmoid junction who underwent surgical resection from 2010 to 2016. Utilization rates of robotic, laparoscopic, and open approaches were examined. Patients were split into cohorts by approach. Subgroup analyses were performed by primary tumor site and surgical procedure. Multivariable analysis was performed by multivariable logistic regression for binary outcomes and multivariable general linear models for continuous outcomes. Survival analysis was performed by Kaplan-Meier and multivariable cox-proportional hazards regression. RESULTS From 2010 to 2016, there was a statistically significant increase in utilization of the robotic and laparoscopic approaches over the study period and a statistically significant decrease in utilization of the open approach. The conversion rates for robotic and laparoscopic cohorts were 7.0% and 15.7%, p < 0.0001. Subgroup analysis revealed statistically lower conversion rates between robotic and laparoscopic approaches for rectosigmoid and rectal tumors and for LAR and APR. Converted cohorts had statistically significant higher odds of short term mortality than the non-converted cohorts (p < 0.05).Laparoscopic conversion had statistically higher odds of positive margins (p < 0.0001) and 30-day unplanned readmission (p < 0.0001) than the laparoscopic non-conversion. Increased adjusted mortality hazard was seen for converted laparoscopy relative to non-converted laparoscopy (p = 0.0019). CONCLUSION From 2010 to 2016, there was a significant increase in utilization of minimally invasive approaches to surgical management of non-metastatic rectal cancer. A robotic approach demonstrated decreased conversion rates than a laparoscopic approach at the rectosigmoid junction and rectum and for LAR and APR. Improved outcomes were seen in the minimally invasive cohorts compared to those that converted to laparotomy.
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