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Burghgraef TA, Geitenbeek RTJ, Broekman M, Hol JC, Hompes R, Consten ECJ. Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study. Surg Endosc 2024; 38:105-115. [PMID: 37932600 PMCID: PMC10776460 DOI: 10.1007/s00464-023-10517-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/08/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The surgical resection of rectal carcinoma is associated with a high risk of permanent stoma rate. Primary anastomosis rate is suggested to be higher in robot-assisted and transanal total mesorectal excision, but permanent stoma rate is unknown. METHODS Patients undergoing total mesorectal excision for MRI-defined rectal cancer between 2015 and 2017 in 11 centers highly experienced in laparoscopic, robot-assisted or transanal total mesorectal excision were included in this retrospective study. Permanent stoma rate, stoma-related complications, readmissions, and reoperations were registered. A multivariable regression analysis was performed for permanent stoma rate, stoma-related complications, and stoma-related reoperations. RESULTS In total, 1198 patients were included. Permanent stoma rate after low anterior resection (with anastomosis or with an end colostomy) was 40.1% in patients undergoing laparoscopic surgery, 21.3% in patients undergoing robot-assisted surgery, and 25.6% in patients undergoing transanal surgery (P < 0.001). Permanent stoma rate after low anterior resection with an anastomosis was 17.3%, 11.8%, and 15.1%, respectively. The robot-assisted and transanal techniques were independently associated with a reduction in permanent stoma rate in patients who underwent a low anterior resection (with anastomosis or with an end colostomy) (OR 0.39 [95% CI 0.25, 0.59] and OR 0.35 [95% CI 0.22, 0.55]), while this was not seen in patients who underwent a restorative low anterior resection. 45.4% of the patients who had a stoma experienced stoma-related complications, 4.0% were at least once readmitted, and 8.9% underwent at least one reoperation. CONCLUSIONS The robot-assisted and transanal techniques are associated with a lower permanent stoma rate in patients who underwent a low anterior resection.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - R T J Geitenbeek
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M Broekman
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J C Hol
- Department of Surgery, Amsterdam UMC, VUmc, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Sikkenk DJ, Sterkenburg AJ, Burghgraef TA, Akol H, Schwartz MP, Arensman R, Verheijen PM, Nagengast WB, Consten ECJ. Robot-assisted fluorescent sentinel lymph node identification in early-stage colon cancer. Surg Endosc 2023; 37:8394-8403. [PMID: 37721591 PMCID: PMC10615938 DOI: 10.1007/s00464-023-10394-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with cT1-2 colon cancer (CC) have a 10-20% risk of lymph node metastases. Sentinel lymph node identification (SLNi) could improve staging and reduce morbidity in future organ-preserving CC surgery. This pilot study aimed to assess safety and feasibility of robot-assisted fluorescence-guided SLNi using submucosally injected indocyanine green (ICG) in patients with cT1-2N0M0 CC. METHODS Ten consecutive patients with cT1-2N0M0 CC were included in this prospective feasibility study. Intraoperative submucosal, peritumoral injection of ICG was performed during a colonoscopy. Subsequently, the near-infrared fluorescence 'Firefly' mode of the da Vinci Xi robotic surgical system was used for SLNi. SLNs were marked with a suture, after which a segmental colectomy was performed. The SLN was postoperatively ultrastaged using serial slicing and immunohistochemistry, in addition to the standard pathological examination of the specimen. Colonoscopy time, detection time (time from ICG injection to first SLNi), and total SLNi time were measured (time from the start of colonoscopy to start of segmental resection). Intraoperative, postoperative, and pathological outcomes were registered. RESULTS In all patients, at least one SLN was identified (mean 2.3 SLNs, SLN diameter range 1-13 mm). No tracer-related adverse events were noted. Median colonoscopy time was 12 min, detection time was 6 min, and total SLNi time was 30.5 min. Two patients had lymph node metastases present in the SLN, and there were no patients with false negative SLNs. No patient was upstaged due to ultrastaging of the SLN after an initial negative standard pathological examination. Half of the patients unexpectedly had pT3 tumours. CONCLUSIONS Robot-assisted fluorescence-guided SLNi using submucosally injected ICG in ten patients with cT1-2N0M0 CC was safe and feasible. SLNi was performed in an acceptable timespan and SLNs down to 1 mm were detected. All lymph node metastases would have been detected if SLN biopsy had been performed.
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Affiliation(s)
- Daan J Sikkenk
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Andrea J Sterkenburg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Halil Akol
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - René Arensman
- Department of Pathology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
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Sikkenk DJ, Sijmons JML, Burghgraef TA, Asaggau I, Vos A, da Costa DW, Somers I, Verheijen PM, Dekker JWT, Nagengast WB, Tanis PJ, Consten ECJ. Nationwide practice in CT-based preoperative staging of colon cancer and concordance with definitive pathology. Eur J Surg Oncol 2023; 49:106941. [PMID: 37442716 DOI: 10.1016/j.ejso.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/31/2023] [Accepted: 05/21/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION In an era of exploring patient-tailored treatment options for colon cancer, preoperative staging is increasingly important. This study aimed to evaluate completeness and reliability of CT-based preoperative locoregional colon cancer staging in Dutch hospitals. MATERIALS AND METHODS Patients who underwent elective oncological resection of colon cancer without neoadjuvant treatment in 77 Dutch hospitals were evaluated between 2011 and 2021. Completeness of T-stage was calculated for individual hospitals and stratified based on a 60% cut-off. Concordance between routine CT-based preoperative locoregional staging (cTN) and definitive pathological staging (pTN) was examined. RESULTS A total of 59,558 patients were included with an average completeness of 43.4% and 53.4% for T and N-stage, respectively. Completeness of T-stage improved from 4.9% in 2011-2014 to 74.4% in 2019-2021. Median completeness for individual hospitals was 53.9% (IQR 27.3-80.5%) and were not significantly different between low and high-volume hospitals. Sensitivity and specificity for T3-4 tumours were relatively low: 75.1% and 76.0%, respectively. cT1-2 tumours were frequently understaged based on a low negative predictive value of 56.8%. Distinction of cT4 and cN2 disease had a high specificity (>95%), but a very low sensitivity (<50%). Positive predictive values of <60% indicated that cT4 and cN1-2 were often overstaged. Completeness and time period did not influence reliability of staging. CONCLUSION Completeness of locoregional staging of colon cancer improved during recent years and varied between hospitals independently from case volume. Discriminating cT1-2 from cT3-4 tumours resulted in substantial understaging and overstaging, additionally cT4 and cN1-2 were overstaged in >40% of cases.
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Affiliation(s)
- Daan J Sikkenk
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Julie M L Sijmons
- Scientific Bureau, Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Ilias Asaggau
- Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Annelotte Vos
- Department of Pathology, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - David W da Costa
- Department of Radiology, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Inne Somers
- Department of Radiology, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Jan-Willem T Dekker
- Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands; Department of Surgery, Meander Medical Centre, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
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Burghgraef TA, Bakker IS, Veld JV, Wijsmuller AR, Amelung FJ, Bemelman WA, Ter Borg F, van Hooft JE, Siersema PD, Tanis PJ, Consten ECJ. Predicting Mortality Within 90 Days of First Intervention in Patients With Left-Sided Obstructive Colon Cancer. Dis Colon Rectum 2023; 66:1309-1318. [PMID: 35522790 DOI: 10.1097/dcr.0000000000002382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute resection for left-sided obstructive colon carcinoma is thought to be associated with a higher mortality risk than a bridge-to-surgery approach using decompressing stoma or self-expandable metal stent, but prediction models are lacking. OBJECTIVE This study aimed to determine the influence of treatment strategy on mortality within 90 days from the first intervention in patients presenting with left-sided obstructive colon carcinoma. DESIGN This was a national multicenter cohort study that used data from a prospective national audit. SETTINGS The study was performed in 75 Dutch hospitals. PATIENTS Patients were included if they underwent resection with curative intent for left-sided obstructive colon carcinoma between 2009 and 2016. INTERVENTIONS First intervention was either acute resection, bridge to surgery with self-expandable metallic stent, or bridge to surgery with decompressing stoma. MAIN OUTCOME MEASURES The main outcome measure was 90-day mortality after the first intervention. Risk factors were identified using multivariable logistic analysis. Subsequently, a risk model was developed. RESULTS In total, 2395 patients were included, with the first intervention consisting of acute resection in 1848 patients (77%), stoma as bridge to surgery in 332 patients (14%), and stent as bridge to surgery in 215 patients (9%). Overall, 152 patients (6.3%) died within 90 days from the first intervention. A decompressing stoma was independently associated with lower 90-day mortality risk (HR, 0.27; 95% CI, 0.094-0.62). Other independent predictors for mortality were age, ASA classification, tumor location, and index levels of serum creatinine and C-reactive protein. The constructed risk model had an area under the curve of 0.84 (95% CI, 0.81-0.87). LIMITATIONS Only patients who underwent surgical resection were included. CONCLUSIONS Treatment strategy had a significant impact on 90-day mortality. A decompressing stoma considerably lowers the risk of mortality, especially in older and frail patients. The developed risk model needs further external validation. See Video Abstract at http://links.lww.com/DCR/B975 .PREDICCIÓN DE LA MORTALIDAD A 90 DÍAS POSTERIORES A LA PRIMERA CIRUGÍA EN PACIENTES CON CÁNCER DE COLON OBSTRUCTIVO DEL LADO IZQUIERDOANTECEDENTES:Se cree que la resección aguda para el carcinoma de colon obstructivo del lado izquierdo está asociada con un mayor riesgo de mortalidad que un enfoque puente a la cirugía que utiliza un estoma de descompresión o un stent metálico autoexpandible, pero faltan modelos de predicción.OBJETIVO:Determinar la influencia de la estrategia de tratamiento sobre la mortalidad dentro de los 90 días desde la primera intervención utilizando un modelo de predicción en pacientes que presentan carcinoma de colon obstructivo del lado izquierdo.DISEÑO:Un estudio de cohorte multicéntrico nacional, utilizando datos de una auditoría nacional prospectiva.ENTORNO CLINICO:El estudio se realizó en 75 hospitales holandeses.PACIENTES:Se incluyeron los pacientes que se sometieron a una resección con intención curativa de un carcinoma de colon obstructivo del lado izquierdo entre 2009 y 2016.INTERVENCIONES:La primera intervención fue resección aguda, puente a cirugía con stent metálico autoexpandible o puente a cirugía con estoma descompresor.PRINCIPALES MEDIDAS DE VALORACIÓN:La principal medida de resultado fue la mortalidad a los 90 días después de la primera intervención. Los factores de riesgo se identificaron mediante análisis logístico multivariable. Posteriormente se desarrolló un modelo de riesgo.RESULTADOS:En total se incluyeron 2395 pacientes, siendo la primera intervención resección aguda en 1848 (77%) pacientes, estoma como puente a la cirugía en 332 (14%) pacientes y stent como puente a la cirugía en 215 (9%) pacientes. En general, 152 pacientes (6,3%) fallecieron dentro de los 90 días posteriores a la primera intervención. Un estoma de descompresión se asoció de forma independiente con un menor riesgo de mortalidad a los 90 días (HR: 0,27, IC: 0,094-0,62). Otros predictores independientes de mortalidad fueron la edad, la clasificación ASA, la ubicación del tumor y los niveles índice de creatinina sérica y proteína C reactiva. El modelo de riesgo construido tuvo un área bajo la curva de 0,84 (IC: 0,81-0,87).LIMITACIONES:Solo se incluyeron pacientes que se sometieron a resección quirúrgica.CONCLUSIONES:La estrategia de tratamiento tuvo un impacto significativo en la mortalidad a los 90 días. Un estoma descompresor reduce considerablemente el riesgo de mortalidad, especialmente en pacientes mayores y frágiles. Se desarrolló un modelo de riesgo, que necesita una mayor validación externa. Consulte Video Resumen en http://links.lww.com/DCR/B975 . (Traducción-Dr. Ingrid Melo ).
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Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Ilsalien S Bakker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Joyce V Veld
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Arthur R Wijsmuller
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Femke J Amelung
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Peter D Siersema
- Departments of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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Burghgraef TA, Rutgers ML, Leijtens JWA, Tuyman JB, Consten ECJ, Hompes R. Completion Total Mesorectal Excision: A Case-Matched Comparison With Primary Resection. Ann Surg Open 2023; 4:e327. [PMID: 37746593 PMCID: PMC10513327 DOI: 10.1097/as9.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives The aim of this study was to compare the perioperative and oncological results of completion total mesorectal excision (cTME) versus primary total mesorectal excision (pTME). Background Early-stage rectal cancer can be treated by local excision alone, which is associated with less surgical morbidity and improved functional outcomes compared with radical surgery. When high-risk histological features are present, cTME is indicated, with possible worse clinical and oncological outcomes compared to pTME. Methods This retrospective cohort study included all patients that underwent TME surgery for rectal cancer performed in 11 centers in the Netherlands between 2015 and 2017. After case-matching, we compared cTME with pTME. The primary outcome was major postoperative morbidity. Secondary outcomes included the rate of restorative procedures and 3-year oncological outcomes. Results In total 1069 patients were included, of which 35 underwent cTME. After matching (1:2 ratio), 29 cTME and 58 pTME were analyzed. No differences were found for major morbidity (27.6% vs 19.0%; P = 0.28) and abdominoperineal excision rate (31.0% vs 32.8%; P = 0.85) between cTME and pTME, respectively. Local recurrence (3.4% vs 8.6%; P = 0.43), systemic recurrence (3.4% vs 12.1%; P = 0.25), overall survival (93.1% vs 94.8%; P = 0.71), and disease-free survival (89.7% vs 81.0%; P = 0.43) were comparable between cTME and pTME. Conclusions cTME is not associated with higher major morbidity, whereas the abdominoperineal excision rate and 3-year oncological outcomes are similar compared to pTME. Local excision as a diagnostic tool followed by completion surgery for early rectal cancer does not compromise outcomes and should still be considered as the treatment of early-stage rectal cancer.
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Affiliation(s)
- Thijs A. Burghgraef
- From the Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
- Department of Surgery, University Medical Centre, Groningen, the Netherlands
| | - Marieke L. Rutgers
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
| | | | - Jurriaan B. Tuyman
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - Esther C. J. Consten
- From the Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
- Department of Surgery, University Medical Centre, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
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Geitenbeek RTJ, Burghgraef TA, Broekman M, Schop BPA, Lieverse TGF, Hompes R, Havenga K, Postma MJ, Consten ECJ. Economic analysis of open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: A systematic review. PLoS One 2023; 18:e0289090. [PMID: 37506122 PMCID: PMC10381040 DOI: 10.1371/journal.pone.0289090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVES Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This systematic review aimed to compare the total, operative and hospitalization costs of open, laparoscopic, robot-assisted and transanal total mesorectal excision. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) (S1 File) A literature review was conducted (end-of-search date: January 1, 2023) and quality assessment performed using the Consensus Health Economic Criteria. RESULTS 12 studies were included, reporting on 2542 patients (226 open, 1192 laparoscopic, 998 robot-assisted and 126 transanal total mesorectal excision). Total costs of minimally invasive total mesorectal excision were higher compared to the open technique in the majority of included studies. For robot-assisted total mesorectal excision, higher operative costs and lower hospitalization costs were reported compared to the open and laparoscopic technique. A meta-analysis could not be performed due to low study quality and a high level of heterogeneity. Heterogeneity was caused by differences in the learning curve and statistical methods used. CONCLUSION Literature regarding costs of total mesorectal excision techniques is limited in quality and number. Available evidence suggests minimally invasive techniques may be more expensive compared to open total mesorectal excision. High-quality economical evaluations, accounting for the learning curve, are needed to properly assess costs of the different techniques.
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Affiliation(s)
- Ritchie T J Geitenbeek
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Mark Broekman
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Bram P A Schop
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Tom G F Lieverse
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centre, Location Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Klaas Havenga
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, Groningen University Medical Center, University of Groningen, Groningen, The Netherlands
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Burghgraef TA, Hol JC, Rutgers ML, Brown G, Hompes R, Sietses C, Consten ECJ. Implications of the new MRI-based rectum definition according to the sigmoid take-off: multicentre cohort study. BJS Open 2023; 7:7100044. [PMID: 37011059 PMCID: PMC10069662 DOI: 10.1093/bjsopen/zrad018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND The introduction of the sigmoid take-off definition might lead to a shift from rectal cancers to sigmoid cancers. The aim of this retrospective cohort study was to determine the clinical impact of the new definition. METHODS In this multicentre retrospective cohort study, patients were included if they underwent an elective, curative total mesorectal excision for non-metastasized rectal cancer between January 2015 and December 2017, were registered in the Dutch Colorectal Audit as having a rectal cancer according to the previous definition, and if MRI was available. All selected rectal cancer cases were reassessed using the sigmoid take-off definition. The primary outcome was the number of patients reassessed with a sigmoid cancer. Secondary outcomes included differences between the newly defined rectal and sigmoid cancer patients in treatment, perioperative results, and 3-year oncological outcomes (overall and disease-free survivals, and local and systemic recurrences). RESULTS Out of 1742 eligible patients, 1302 rectal cancer patients were included. Of these, 170 (13.1 per cent) were reclassified as having sigmoid cancer. Among these, 93 patients (54.7 per cent) would have been offered another adjuvant or neoadjuvant treatment according to the Dutch guideline. Patients with a sigmoid tumour after reassessment had a lower 30-day postoperative complication rate (33.5 versus 48.3 per cent, P < 0.001), lower reintervention rate (8.8 versus 17.4 per cent, P < 0.007), and a shorter length of stay (a median of 5 days (i.q.r. 4-7) versus a median of 6 days (i.q.r. 5-9), P < 0.001). Three-year oncological outcomes were comparable. CONCLUSION Using the anatomical landmark of the sigmoid take-off, 13.1 per cent of the previously classified patients with rectal cancer had sigmoid cancer, and 54.7 per cent of these patients would have been treated differently with regard to neoadjuvant therapy or adjuvant therapy.
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Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeroen C Hol
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Marieke L Rutgers
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Gina Brown
- Department of Radiology, Royal Marsden, London, UK
- Department of Radiology, Imperial College London, London, UK
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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8
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Hol JC, Burghgraef TA, Rutgers MLW, Crolla RMPH, van Geloven AAW, de Jong GM, Hompes R, Leijtens JWA, Polat F, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Consten ECJ, Sietses C. Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer. Surg Endosc 2023; 37:1916-1932. [PMID: 36258000 PMCID: PMC10017638 DOI: 10.1007/s00464-022-09669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity. METHODS Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity. RESULTS In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%. CONCLUSIONS The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.
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Affiliation(s)
- Jeroen C Hol
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, De Boelelaan 117, 1081 HB, Amsterdam, The Netherlands.
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands.
| | - Thijs A Burghgraef
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marieke L W Rutgers
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | - Gabie M de Jong
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, De Boelelaan 117, 1081 HB, Amsterdam, The Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
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9
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Burghgraef TA, Sikkenk DJ, Crolla RMPH, Fahim M, Melenhorst J, Moumni ME, Schelling GVD, Smits AB, Stassen LPS, Verheijen PM, Consten ECJ. Assessing the learning curve of robot-assisted total mesorectal excision: a multicenter study considering procedural safety, pathological safety, and efficiency. Int J Colorectal Dis 2023; 38:9. [PMID: 36630001 PMCID: PMC9834356 DOI: 10.1007/s00384-022-04303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Evidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore, this study aims to assess the learning curve of robot-assisted total mesorectal excision. METHODS A retrospective study was performed in four Dutch centers. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications, and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared. RESULTS In this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12 to 35 cases. Intraoperative, postoperative, and pathological outcomes did not differ between patients operated during and after the learning curve. CONCLUSION The learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined limits and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.
| | - D J Sikkenk
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M Fahim
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M El Moumni
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - A B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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10
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Zamaray B, Veld JV, Burghgraef TA, Brohet R, van Westreenen HL, van Hooft JE, Siersema PD, Tanis PJ, Consten ECJ, Amelung F, Bastiaenen V, van der Bilt J, Burghgraef T, Draaisma W, de Groot J, Kok N, Kusters M, Nagtegaal I, Zwanenburg E. Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model. Eur J Surg Oncol 2022; 49:738-746. [PMID: 36641294 DOI: 10.1016/j.ejso.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS. MATERIALS AND METHODS Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T0) and after resection, in patients having a stoma in situ (T1). These risk factors were used to construct a web-based prediction tool. RESULTS Of 2099 patients included in the study (T0), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T1), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T0 and T1 population. Other predictors at T0 were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T1, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T0 and an AUC of 0.81 for T1. CONCLUSIONS PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.
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Affiliation(s)
- Bobby Zamaray
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - J V Veld
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - T A Burghgraef
- Department of Surgery, Meander Hospital, Amersfoort, the Netherlands
| | - R Brohet
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands
| | | | - J E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Location AMC, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands; Department of Oncological and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands; Department of Surgery, Meander Hospital, Amersfoort, the Netherlands.
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11
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Hol JC, Burghgraef TA, Rutgers MLW, Crolla RMPH, van Geloven NAW, Leijtens JWA, Polat F, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Consten ECJ, Hompes R, Sietses C. Comparison of three-year oncological results after restorative low anterior resection, non-restorative low anterior resection and abdominoperineal resection for rectal cancer. European Journal of Surgical Oncology 2022; 49:730-737. [PMID: 36460530 DOI: 10.1016/j.ejso.2022.11.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/31/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Oncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR). MATERIALS AND METHODS This retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate. RESULTS Of 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001. CONCLUSION NRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.
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Affiliation(s)
- Jeroen C Hol
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, Amsterdam, the Netherlands; Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands.
| | - Thijs A Burghgraef
- Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marieke L W Rutgers
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | | | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam University Medical Center, Location VU Medical Centre, Amsterdam, the Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center, Location Academic Medical Centre, Amsterdam, the Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands
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12
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Burghgraef TA, Sikkenk DJ, Verheijen PM, Moumni ME, Hompes R, Consten ECJ. The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review. Surg Endosc 2022; 36:6337-6360. [PMID: 35697853 PMCID: PMC9402498 DOI: 10.1007/s00464-022-09087-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME. METHODS A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias. RESULTS 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods. CONCLUSION Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
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Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Daan J Sikkenk
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Mostafa El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, University Medical Center Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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13
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Geitenbeek RTJ, Burghgraef TA, Broekman M, Schop BPA, Lieverse TGF, Hompes R, Havenga K, Postma M, Consten ECJ. Cost analysis and cost-effectiveness of open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in patients with rectal cancer: a protocol for a systematic review. BMJ Open 2022; 12:e057803. [PMID: 35981773 PMCID: PMC9394195 DOI: 10.1136/bmjopen-2021-057803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Nowadays, most rectal tumours are treated open or minimally invasive, using laparoscopic, robot-assisted or transanal total mesorectal excision. However, insight into the total costs of these techniques is limited. Since all three techniques are currently being performed, including cost considerations in the choice of treatment technique may significantly impact future healthcare costs. Therefore, this systematic review aims to provide an overview of evidence regarding costs in patients with rectal cancer following open, laparoscopic, robot-assisted and transanal total mesorectal excision. METHODS AND ANALYSIS A systematic search will be conducted for papers between January 2000 and March 2022. Databases PubMed/MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library databases will be searched. Study selection, data extraction and quality assessment will be performed independently by four reviewers and discrepancies will be resolved through discussion. The Consensus Health Economic Criteria list will be used for assessing risk of bias. Total costs of the different techniques, consisting of but not limited to, theatre, in-hospital and postoperative costs, will be the primary outcome. ETHICS AND DISSEMINATION No ethical approval is required, as there is no collection of patient data at an individual level. Findings will be disseminated widely, through peer-reviewed publication and presentation at relevant national and international conferences. TRIAL REGISTRATION NUMBER CRD42021261125.
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Affiliation(s)
- Ritchie T J Geitenbeek
- Department of Surgery, Meander MC, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, Meander MC, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Mark Broekman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bram P A Schop
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Tom G F Lieverse
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Klaas Havenga
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maarten Postma
- Department of Health Sciences, University Medical Centre Groningen, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander MC, Amersfoort, The Netherlands
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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14
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Fahim M, Dijksman LM, Burghgraef TA, van der Nat PB, Derksen WJM, van Santvoort HC, Pultrum BB, Consten ECJ, Biesma DH, Smits AB. Increased long-term mortality after open colorectal cancer surgery: a multicentre population-based study. Response to the letter of Mroczkowski et al. Colorectal Dis 2022; 24:235-236. [PMID: 34729901 DOI: 10.1111/codi.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Milad Fahim
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Lea M Dijksman
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Paul B van der Nat
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.,Cancer Center, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Bareld B Pultrum
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, MeanderMC, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Douwe H Biesma
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Anke B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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15
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Burghgraef TA, Hol JC, Rutgers ML, Crolla RMPH, van Geloven AAW, Hompes R, Leijtens JWA, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Polat F, Verheijen PM, Sietses C, Consten ECJ. ASO Visual Abstract: Laparoscopic Versus Robot-Assisted Versus Transanal Low Anterior Resection: 3-Year Oncologic Results of a Population-Based Cohort in Experienced Centers. Ann Surg Oncol 2022. [PMID: 34988839 DOI: 10.1245/s10434-021-10894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T A Burghgraef
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - J C Hol
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands.,Department of Surgery, Amsterdam UMC, Locatie VUmc, Amsterdam, the Netherlands
| | - M L Rutgers
- Department of Surgery, Amsterdam UMC, Locatie AMC, Amsterdam, the Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | | | - R Hompes
- Department of Surgery, Amsterdam UMC, Locatie AMC, Amsterdam, the Netherlands
| | - J W A Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, the Netherlands
| | - A Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Locatie VUmc, Amsterdam, the Netherlands
| | - E G G Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - F Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - C Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands. .,Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
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16
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Burghgraef TA, Hol JC, Rutgers ML, Crolla RMPH, van Geloven AAW, Hompes R, Leijtens JWA, Polat F, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Verheijen PM, Sietses C, Consten ECJ. Laparoscopic Versus Robot-Assisted Versus Transanal Low Anterior Resection: 3-Year Oncologic Results for a Population-Based Cohort in Experienced Centers. Ann Surg Oncol 2021; 29:1910-1920. [PMID: 34608557 PMCID: PMC8810464 DOI: 10.1245/s10434-021-10805-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/31/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic, robot-assisted, and transanal total mesorectal excision are the minimally invasive techniques used most for rectal cancer surgery. Because data regarding oncologic results are lacking, this study aimed to compare these three techniques while taking the learning curve into account. METHODS This retrospective population-based study cohort included all patients between 2015 and 2017 who underwent a low anterior resection at 11 dedicated centers that had completed the learning curve of the specific technique. The primary outcome was overall survival (OS) during a 3-year follow-up period. The secondary outcomes were 3-year disease-free survival (DFS) and 3-year local recurrence rate. Statistical analysis was performed using Cox-regression. RESULTS The 617 patients enrolled in the study included 252 who underwent a laparoscopic resection, 205 who underwent a robot-assisted resection, and 160 who underwent a transanal low anterior resection. The oncologic outcomes were equal between the three techniques. The 3-year OS rate was 90% for laparoscopic resection, 90.4% for robot-assisted resection, and 87.6% for transanal low anterior resection. The 3-year DFS rate was 77.8% for laparoscopic resection, 75.8% for robot-assisted resection, and 78.8% for transanal low anterior resection. The 3-year local recurrence rate was in 6.1% for laparoscopic resection, 6.4% for robot-assisted resection, and 5.7% for transanal procedures. Cox-regression did not show a significant difference between the techniques while taking confounders into account. CONCLUSION The oncologic results during the 3-year follow-up were good and comparable between laparoscopic, robot-assisted, and transanal total mesorectal technique at experienced centers. These techniques can be performed safely in experienced hands.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - J C Hol
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands.,Department of Surgery, Amsterdam UMC, Locatie VUmc, Amsterdam, The Netherlands
| | - M L Rutgers
- Department of Surgery, Amsterdam UMC, Locatie AMC, Amsterdam, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - R Hompes
- Department of Surgery, Amsterdam UMC, Locatie AMC, Amsterdam, The Netherlands
| | - J W A Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - F Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - A Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Locatie VUmc, Amsterdam, The Netherlands
| | - E G G Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - C Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands. .,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.
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17
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Fahim M, Dijksman LM, Burghgraef TA, van der Nat PB, Derksen WJM, van Santvoort HC, Pultrum BB, Consten ECJ, Biesma DH, Smits AB. Increased long-term mortality after open colorectal cancer surgery: A multicentre population-based study. Colorectal Dis 2021; 23:2567-2574. [PMID: 34173995 DOI: 10.1111/codi.15793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/20/2021] [Accepted: 06/09/2021] [Indexed: 12/23/2022]
Abstract
AIM Unlike meta-analyses of randomized controlled trials, population-based studies in colorectal cancer (CRC) patients have shown a significant association between open surgery and increased 30- and 90-day mortality compared with laparoscopic surgery. Long-term mortality, however, is scarcely reported. This retrospective population-based study aimed to compare long-term mortality after open and laparoscopic surgery for CRC. METHOD The Dutch Colorectal Audit and the Dutch Cancer Centre registry were used to identify patients from three large nonacademic teaching hospitals who underwent curative resection for CRC between 2009 and 2018. Patients with relative contraindications for laparoscopic surgery (cT4 or pT4 tumours, distant metastasis requiring additional resection and emergency surgery) were excluded. Multivariable regression was used to assess the effect of laparoscopic surgery on long-term mortality with adjustment for gender, age, American Society of Anesthesiologists score, TNM stage, chemoradiation therapy and other confounders. RESULTS We included 4531 patients, of whom 1298 (29%) underwent open surgery. The median follow-up was 43 months (interquartile range 23-71 months). Open surgery was associated with an increased risk of long-term mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.10-1.45, p = 0.001). Mixed-effects Cox regression with year of surgery as a random effect also showed an increased risk after open surgery (adjusted hazard ratio 1.33, 95% confidence interval 1.11-1.52, p = 0.004). CONCLUSION Open surgery seems to be associated with increased long-term mortality in the elective setting for CRC patients. A minimally invasive approach might improve long-term outcomes.
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Affiliation(s)
- Milad Fahim
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Lea M Dijksman
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Paul B van der Nat
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.,Cancer Center, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Bareld B Pultrum
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander MC, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Douwe H Biesma
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Anke B Smits
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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18
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Hol JC, Burghgraef TA, Rutgers MLW, Crolla RMPH, van Geloven NAW, Hompes R, Leijtens JWA, Polat F, Pronk A, Smits AB, Tuynman JB, Verdaasdonk EGG, Consten ECJ, Sietses C. Comparison of laparoscopic versus robot-assisted versus transanal total mesorectal excision surgery for rectal cancer: a retrospective propensity score-matched cohort study of short-term outcomes. Br J Surg 2021; 108:1380-1387. [PMID: 34370834 DOI: 10.1093/bjs/znab233] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Laparoscopic total mesorectal excision (TME) surgery for rectal cancer has important technical limitations. Robot-assisted and transanal TME (TaTME) may overcome these limitations, potentially leading to lower conversion rates and reduced morbidity. However, comparative data between the three approaches are lacking. The aim of this study was to compare short-term outcomes for laparoscopic TME, robot-assisted TME and TaTME in expert centres. METHODS Patients undergoing rectal cancer surgery between 2015 and 2017 in expert centres for laparoscopic, robot-assisted or TaTME were included. Outcomes for TME surgery performed by the specialized technique in the expert centres were compared after propensity score matching. The primary outcome was conversion rate. Secondary outcomes were morbidity and pathological outcomes. RESULTS A total of 1078 patients were included. In rectal cancer surgery in general, the overall rate of primary anastomosis was 39.4, 61.9 and 61.9 per cent in laparoscopic, robot-assisted and TaTME centres respectively (P < 0.001). For specialized techniques in expert centres excluding abdominoperineal resection (APR), the rate of primary anastomosis was 66.7 per cent in laparoscopic, 89.8 per cent in robot-assisted and 84.3 per cent in TaTME (P < 0.001). Conversion rates were 3.7 , 4.6 and 1.9 per cent in laparoscopic, robot-assisted and TaTME respectively (P = 0.134). The number of incomplete specimens, circumferential resection margin involvement rate and morbidity rates did not differ. CONCLUSION In the minimally invasive treatment of rectal cancer more primary anastomoses are created in robotic and TaTME expert centres.
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Affiliation(s)
- J C Hol
- Department of Surgery, Amsterdam University Medical Centre, location VU Medical Centre, Amsterdam, The Netherlands.,Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - T A Burghgraef
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - M L W Rutgers
- Department of Surgery, Amsterdam University Medical Centre, location Academic Medical Centre, Amsterdam, The Netherlands
| | - R M P H Crolla
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - R Hompes
- Department of Surgery, Amsterdam University Medical Centre, location Academic Medical Centre, Amsterdam, The Netherlands
| | - J W A Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - F Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - A Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam University Medical Centre, location VU Medical Centre, Amsterdam, The Netherlands
| | - E G G Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - C Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
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19
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Souwer ETD, Bastiaannet E, Steyerberg EW, Dekker JWT, Steup WH, Hamaker MM, Sonneveld DJA, Burghgraef TA, van den Bos F, Portielje JEA. A Prediction Model for Severe Complications after Elective Colorectal Cancer Surgery in Patients of 70 Years and Older. Cancers (Basel) 2021; 13:cancers13133110. [PMID: 34206349 PMCID: PMC8268502 DOI: 10.3390/cancers13133110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Older patients have an increased risk of morbidity and mortality after colorectal cancer (CRC) surgery. Existing CRC surgical prediction models have not incorporated geriatric predictors, limiting applicability for preoperative decision-making. The objective was to develop and internally validate a predictive model based on preoperative predictors, including geriatric characteristics, for severe postoperative complications after elective surgery for stage I-III CRC in patients ≥70 years. PATIENTS AND METHODS A prospectively collected database contained 1088 consecutive patients from five Dutch hospitals (2014-2017) with 171 severe complications (16%). The least absolute shrinkage and selection operator (LASSO) method was used for predictor selection and prediction model building. Internal validation was done using bootstrapping. RESULTS A geriatric model that included gender, previous DVT or pulmonary embolism, COPD/asthma/emphysema, rectal cancer, the use of a mobility aid, ADL assistance, previous delirium and polypharmacy showed satisfactory discrimination with an AUC of 0.69 (95% CI 0.73-0.64); the AUC for the optimism corrected model was 0.65. Based on these predictors, the eight-item colorectal geriatric model (GerCRC) was developed. CONCLUSION The GerCRC is the first prediction model specifically developed for older patients expected to undergo CRC surgery. Combining tumour- and patient-specific predictors, including geriatric predictors, improves outcome prediction in the heterogeneous older population.
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Affiliation(s)
- Esteban T. D. Souwer
- Department of Internal Medicine, Haga Hospital, 2545 AA Den Haag, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
- Correspondence:
| | - Esther Bastiaannet
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
| | - Ewout W. Steyerberg
- Department of Medical Statistics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Jan Willem T. Dekker
- Department of Surgery, Reinier De Graaf Gasthuis, 2625 AD Delft, The Netherlands;
| | - Willem H. Steup
- Department of Surgery, Haga Hospital, 2545 AA Den Haag, The Netherlands;
| | - Marije M. Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, 3582 KE Utrecht, The Netherlands;
| | | | - Thijs A. Burghgraef
- Department of Surgery, Meander Medisch Centrum, 3813 TZ Amersfoort, The Netherlands;
| | - Frederiek van den Bos
- Department of Geriatric Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Johanna E. A. Portielje
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
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20
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Burghgraef TA, Zweep AL, Sikkenk DJ, van der Pas MHGM, Verheijen PM, Consten ECJ. In vivo sentinel lymph node identification using fluorescent tracer imaging in colon cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2020; 158:103149. [PMID: 33450679 DOI: 10.1016/j.critrevonc.2020.103149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The use of fluorescence might improve the performance of the sentinel lymph node procedure in patients with colon cancer. This systematic review was conducted to gain insight in the performance and applicability of the sentinel lymph node procedure using fluorescence. METHOD A systematic literature search was performed. Databases were searched for prospective studies concerning sentinel node identification using fluorescence in colon cancer. Detection rate, accuracy rate and sensitivity of the sentinel lymph node procedure were calculated for early stage (T1-T2) and more invasive (T3-T4) tumours. RESULTS Analyses of five included studies showed for respectively T3-T4 and T1-T2 tumours a detection rate of 90 % and 91 %, an accuracy rate of 77 % and 98 %, and a sensitivity of 30 % and 80 %. CONCLUSION The sentinel lymph node procedure using fluorescence in early stage (T1-T2) colon cancer seems to be promising. Larger cohorts are necessary to confirm these results.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands.
| | - A L Zweep
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - D J Sikkenk
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | | | - P M Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
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21
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Burghgraef TA, Amelung FJ, Verheijen PM, Broeders IAMJ, Consten ECJ. Intestinal motility distal of a deviating ileostomy after rectal resection with the construction of a primary anastomosis: results of the prospective COLO-MOVE study. Int J Colorectal Dis 2020; 35:1959-1962. [PMID: 32504330 PMCID: PMC7508735 DOI: 10.1007/s00384-020-03651-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE No consensus exists regarding the use of preoperative bowel preparation for patients undergoing a low anterior resection (LAR). Several comparative studies show similar outcomes when a single time enema (STE) is compared with mechanical bowel preparation (MBP). It is hypothesized that STE is comparable with MBP due to a decrease in intestinal motility distal of a newly constructed diverting ileostomy (DI). METHODS In this prospective single-centre cohort study, patients undergoing a LAR with primary anastomosis and DI construction were given a STE 2 h pre-operatively. Radio-opaque markers were inserted in the efferent loop of the DI during surgery, and plain abdominal X-rays were made during the first, third, fifth and seventh postoperative day to visualize intestinal motility. RESULTS Thirty-nine patients were included. Radio-opaque markers were situated in the ileum or right colon in 100%, 100% and 97.1% of the patients during respectively the first, third and fifth postoperative day. One patient had its most distal marker situated in the left colon during day five. In none of the patients, the markers were seen distal of the anastomosis. CONCLUSION Intestinal motility distally of the DI is decreased in patients who undergo a LAR resection with the construction of an anastomosis and DI, while preoperatively receiving a STE.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813, TZ, Amersfoort, the Netherlands.
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, the Netherlands.
| | - F J Amelung
- Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - P M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813, TZ, Amersfoort, the Netherlands
| | - I A M J Broeders
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813, TZ, Amersfoort, the Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813, TZ, Amersfoort, the Netherlands
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713, GZ, Groningen, the Netherlands
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22
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van den Boom AL, de Wijkerslooth EML, van Rosmalen J, Beverdam FH, Boerma EJG, Boermeester MA, Bosmans JWAM, Burghgraef TA, Consten ECJ, Dawson I, Dekker JWT, Emous M, van Geloven AAW, Go PMNYH, Heijnen LA, Huisman SA, Jean Pierre D, de Jonge J, Kloeze JH, Koopmanschap MA, Langeveld HR, Luyer MDP, Melles DC, Mouton JW, van der Ploeg APT, Poelmann FB, Ponten JEH, van Rossem CC, Schreurs WH, Shapiro J, Steenvoorde P, Toorenvliet BR, Verhelst J, Versteegh HP, Wijnen RMH, Wijnhoven BPL. Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial. Trials 2018; 19:263. [PMID: 29720238 PMCID: PMC5932884 DOI: 10.1186/s13063-018-2629-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. Methods Patients of 8 years and older undergoing appendectomy for acute complex appendicitis – defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess – are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. Discussion This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. Trial registration Dutch Trial Register, NTR6128. Registered on 20 December 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2629-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Loes van den Boom
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elisabeth M L de Wijkerslooth
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marja A Boermeester
- Department of Surgery, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | | | | | | | - Imro Dawson
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | | | - Marloes Emous
- Department of Surgery, MC Leeuwarden, Leeuwarden, The Netherlands
| | | | - Peter M N Y H Go
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Luc A Heijnen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Sander A Huisman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Joske de Jonge
- Department of Surgery, Tergooi, Hilversum/Blaricum, The Netherlands
| | - Jurian H Kloeze
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marc A Koopmanschap
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Hester R Langeveld
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Damian C Melles
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Jeroen E H Ponten
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | | | - Joël Shapiro
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Joost Verhelst
- Department of Surgery, Ikazia Ziekenhuis, Rotterdam, The Netherlands
| | - Hendt P Versteegh
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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