1
|
Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg 2023; 158:1303-1310. [PMID: 37728932 PMCID: PMC10512167 DOI: 10.1001/jamasurg.2023.4389] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/10/2023] [Indexed: 09/22/2023]
Abstract
Importance Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. Objective To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. Design, Setting, and Participants This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Exposure Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. Main Outcomes and Measures The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. Results A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). Conclusions and Relevance This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.
Collapse
Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor
- Department of Economics, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Section Editor, JAMA Surgery
| | - Kyle H. Sheetz
- Department of Surgery, University of California, San Francisco
| |
Collapse
|
2
|
Sterk MFM, Crolla RMPH, Verseveld M, Dekker JWT, van der Schelling GP, Verhoef C, Olthof PB. Uptake of robot-assisted colon cancer surgery in the Netherlands. Surg Endosc 2023; 37:8196-8203. [PMID: 37644155 PMCID: PMC10615967 DOI: 10.1007/s00464-023-10383-5] [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: 06/02/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The robot-assisted approach is now often used for rectal cancer surgery, but its use in colon cancer surgery is less well defined. This study aims to compare the outcomes of robotic-assisted colon cancer surgery to conventional laparoscopy in the Netherlands. METHODS Data on all patients who underwent surgery for colon cancer from 2018 to 2020 were collected from the Dutch Colorectal Audit. All complications, readmissions, and deaths within 90 days after surgery were recorded along with conversion rate, margin and harvested nodes. Groups were stratified according to the robot-assisted and laparoscopic approach. RESULTS In total, 18,886 patients were included in the analyses. The operative approach was open in 15.2%, laparoscopic in 78.9% and robot-assisted in 5.9%. The proportion of robot-assisted surgery increased from 4.7% in 2018 to 6.9% in 2020. There were no notable differences in outcomes between the robot-assisted and laparoscopic approach for Elective cT1-3M0 right, left, and sigmoid colectomy. Only conversion rate was consistently lower in the robotic group. (4.6% versus 8.8%, 4.6% versus 11.6%, and 1.6 versus 5.9%, respectively). CONCLUSIONS This nationwide study on surgery for colon cancer shows there is a gradual but slow adoption of robotic surgery for colon cancer up to 6.9% in 2020. When comparing the outcomes of right, left, and sigmoid colectomy, clinical outcomes were similar between the robotic and laparoscopic approach. However, conversion rate is consistently lower in the robotic procedures.
Collapse
Affiliation(s)
| | | | - Mareille Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | | | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
- Department of Surgery, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015GD, Rotterdam, The Netherlands.
| |
Collapse
|
3
|
Hahnloser D, Rrupa D, Grass F. Feasibility of on-demand robotics in colorectal surgery: first cases. Surg Endosc 2023; 37:8594-8600. [PMID: 37488444 PMCID: PMC10615910 DOI: 10.1007/s00464-023-10284-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The key benefits of robotics are improved precision and control, thanks to fully articulated robotic instruments and enhanced, stable endoscope control. However, colorectal procedures also require large movements such as medialization of the colon where a robotic platform is not always needed. We present the world's first experience in colorectal surgery with a new open platform of on-demand robotics. METHODS AND PROCEDURES Standard laparoscopic 3-D camera, insufflator, trocars and energy devices, available in all hospitals performing laparoscopic surgery, are used in combination with the Dexter System™ from Distalmotion SA, which includes two robotic instrument arms, one robotic endoscope arm and a sterile surgeon console. We present the first 12 colorectal cases of robotic assisted ventral mesh rectopexy (n = 2), oncologic right colectomies (n = 8), transverse colectomy (n = 1) and ileocecal resection (n = 1) using the Dexter System. RESULTS The two ventral mesh rectopexies were fully robotic, requiring no switching from standard laparoscopy to robotic assistance. The robotic platform was used for central vascular ligation (CVL) in all 8 oncologic colectomies, whereas medialization of the colon and transection was performed with standard laparoscopy. The switch from laparoscopy to robotics and back was performed in 15-30 s. Intracorporal anastomosis was performed in 4 patients (stapling by standard laparoscopy and suturing of the defect with robotic assistance). Conversion or permanent switch to standard laparoscopy was required in two patients due to visceral obesity. No robotic platform-related intraoperative adverse event occurred. No major morbidity occurred at 60 days. CONCLUSIONS On-demand robotics is feasible and combines the best of two worlds: Robotics where precision and enhanced dexterity are required and standard laparoscopy where it is at its best. The surgeon remains scrubbed-in at all times, allowing a switch between robotics and laparoscopy within seconds.
Collapse
Affiliation(s)
- Dieter Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
| | - Djana Rrupa
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Fabian Grass
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| |
Collapse
|
4
|
Unruh K, Stovall S, Chang L, Deal S, Kaplan JA, Moonka R, Simianu VV. Implementation of a structured robotic colorectal curriculum for general surgery residents. J Robot Surg 2023; 17:2331-2338. [PMID: 37378796 DOI: 10.1007/s11701-023-01660-5] [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: 05/02/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.
Collapse
Affiliation(s)
- Kenley Unruh
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA.
| | - Stephanie Stovall
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Lily Chang
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Shanley Deal
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| | - Vlad V Simianu
- Department of Surgery, Virginia Mason Franciscan Health, Virginia Mason Medical Center, 1100 9Th Ave, Seattle, WA, 98101, USA
| |
Collapse
|
5
|
Baracy MG, Kerl A, Hagglund K, Fennell B, Corey L, Aslam MF. Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020. J Robot Surg 2023; 17:2211-2220. [PMID: 37280406 DOI: 10.1007/s11701-023-01631-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/21/2023] [Indexed: 06/08/2023]
Abstract
The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approach to hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI - 2.3 to - 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI - 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients.
Collapse
Affiliation(s)
- Michael G Baracy
- Department of Obstetrics and Gynecology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, MI, 48236, USA.
| | - Alexis Kerl
- Department of Family Medicine, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Karen Hagglund
- Department of Biomedical Investigations and Research, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Brian Fennell
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, 48202, USA
| | - Logan Corey
- Department of Gynecologic Oncology, Wayne State University, Detroit, MI, 48202, USA
| | - Muhammad Faisal Aslam
- Department of Female Pelvic Medicine and Reconstructive Surgery, Ascension St. John Hospital, Detroit, MI, 48236, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| |
Collapse
|
6
|
Gillani M, Rosen SA. Current Controversies in the Management of Locally Advanced Colon Cancer. Am Surg 2023:31348231175490. [PMID: 37183413 DOI: 10.1177/00031348231175490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Mishal Gillani
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Seth Alan Rosen
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
7
|
Cios K, Janjua H, Rogers MP, Read M, Docimo S, Kuo PC. Determining the value proposition of surgical care in CMS star rated hospitals. Am J Surg 2023; 225:541-544. [PMID: 36462958 DOI: 10.1016/j.amjsurg.2022.11.022] [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: 07/08/2022] [Revised: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND CMS Hospital Quality Star ratings reflect the quality of care given to patients. It is hypothesized that increased Star-rating is associated with higher cost and that the value proposition is diminished. METHODS This study used the Florida AHCA inpatient dataset, CY2019. Partial colectomy was selected as a representative inpatient surgical procedure. Analysis was performed on this data to compare high and low Star-rated hospitals. RESULTS Total costs were equivalent among all Star levels on initial analysis. In a propensity matched comparison with 1 Star, 5 Star hospitals had significantly lower length-of-stay and ICU, anesthesia, radiology and lab costs, and conversely, had higher total (+2%), operating room and med-surg supply costs. CONCLUSIONS These results demonstrate that total colectomy costs are functionally equivalent among the CMS 1- and 5- Star categories. The results indicate that higher CMS Star ratings fulfill the value proposition and indeed offer higher quality without significantly increased cost.
Collapse
Affiliation(s)
- Konrad Cios
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Haroon Janjua
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael P Rogers
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Meagan Read
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Salvatore Docimo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| |
Collapse
|
8
|
Deng C, Wu B. Laparoscopic resection of presacral benign tumors with rectum preservation. Updates Surg 2023; 75:781-784. [PMID: 36795320 DOI: 10.1007/s13304-023-01457-z] [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: 12/11/2022] [Accepted: 02/07/2023] [Indexed: 02/17/2023]
Abstract
Multiple surgical approaches are available for the treatment of presacral tumors. In patients with presacral tumors, surgical resection is currently the only curative treatment option. However, the anatomical structures of the pelvis are not readily accessible using traditional approaches. Herein, we present a surgical technique for laparoscopic presacral benign tumor resection with rectal preservation. Surgical videos of two patients were used to introduce the laparoscopic procedure. First, the tumor of a 30-year-old woman with presacral cysts was observed during physical examination. As the tumor continued to enlarge, it increased rectal compression and altered bowel habits. The patient's surgical video was used to present complete laparoscopic presacral resection. Several video clips of a second 30-year-old woman with cysts were used to present the details and precautions of the resection. Neither of the patients required conversion to an open surgical approach. Complete surgical excision of the tumors was achieved, without rectal injury. Both patients had no postoperative complications and were discharged on postoperative 5-6 days. The laparoscopic approach for presacral benign tumors is superior in terms of manipulability compared with the conventional approach. Therefore, we recommend that the laparoscopy approach should be considered as the standard surgical approach for presacral benign tumors.
Collapse
Affiliation(s)
- Chaolin Deng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
9
|
Curfman KR, Blair GE, Pille SA, Kosnik CL, Rashidi L. The patient perspective of same day discharge colectomy: one hundred patients surveyed on their experience following colon surgery. Surg Endosc 2023; 37:134-139. [PMID: 35854124 PMCID: PMC9296012 DOI: 10.1007/s00464-022-09446-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 07/04/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Guided by enhanced recovery after surgery protocols and coerced by constraints of the Coronavirus Disease 2019, the concept of same day discharge (SDD) after colon surgery is becoming a topic of great interest. Although only a few literature sources are published on the topic and protocols, the number of centers interested in SDD is increasing. With the small number of sources on protocol, safety, implementation, and criteria, there has yet to be a review of the patient experience and satisfaction. METHODS Our institution has one of the largest American databases of SDD colon surgery. We performed a retrospective patient survey assessing perception of their surgical experience and satisfaction, which analyzed patients from February 2019 to January 2022. Fifty SDD patients were selected for participation, as well as fifty patients who were discharged on postoperative day 1 (POD1). An eleven-question survey was offered to patients and responses recorded. RESULTS One hundred patients were contacted, 50 SDD and 50 POD1. Of the SDD patients, 41/50 (82%) patients participated in the survey, while 23/50 (46%) of POD1 patients participated. The highest average response in both populations was an understanding of patient postoperative mobility instructions (9.27/10, 9.68/10). The lowest average response in the SDD population was family comfort with discharge (8.17/10), while patient comfort with discharge was lowest in the POD1 group, (8.56/10). Importantly, we observed that 85.37% of patients who underwent SDD would do so again if given the opportunity. The only statistically significant variable was a difference in comfort with postoperative pain control, favoring the POD1 group, p = 0.02. CONCLUSIONS SDD colon surgery is a feasible and reproducible option. Only comfort with postoperative pain control found a statistical difference, which we intend to improve upon with postanesthesia care unit education. Of patients reviewed who underwent SDD, most patients enjoyed their experience and would undergo SDD again.
Collapse
|
10
|
Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
11
|
Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
Collapse
Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
| |
Collapse
|
12
|
Aggarwal A, Han L, Boyle J, Lewis D, Kuyruba A, Braun M, Walker K, Fearnhead N, Sullivan R, van der Meulen J. Association of Quality and Technology With Patient Mobility for Colorectal Cancer Surgery. JAMA Surg 2023; 158:e225461. [PMID: 36350616 PMCID: PMC9647575 DOI: 10.1001/jamasurg.2022.5461] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Importance Many health care systems publish hospital-level quality measures as a driver of hospital performance and to support patient choice, but it is not known if patients with cancer respond to them. Objective To investigate hospital quality and patient factors associated with treatment location. Design, Setting, and Participants This choice modeling study used national administrative hospital data. Patients with colon and rectal cancer treated in all 163 English National Health Service (NHS) hospitals delivering colorectal cancer surgery between April 2016 and March 2019 were included. The extent to which patients chose to bypass their nearest surgery center was investigated, and conditional logistic regression was used to estimate the association of additional travel time, hospital quality measures, and patient characteristics with treatment location. Exposures Additional travel time in minutes, hospital characteristics, and patient characteristics: age, sex, cancer T stage, socioeconomic status, comorbidity, and rural or urban residence. Main Outcomes and Measures Treatment location. Results Overall, 44 299 patients were included in the final cohort (mean [SD] age, 68.9 [11.6] years; 18 829 [42.5%] female). A total of 8550 of 31 258 patients with colon cancer (27.4%) and 3933 of 13 041 patients with rectal cancer (30.2%) bypassed their nearest surgical center. Travel time was strongly associated with treatment location. The association was less strong for younger, more affluent patients and those from rural areas. For rectal cancer, patients were more likely to travel to a hospital designated as a specialist colorectal cancer surgery center (odds ratio, 1.45; 95% CI, 1.13-1.87; P = .004) and to a hospital performing robotic surgery for rectal cancer (odds ratio, 1.43; 95% CI, 1.11-1.86; P = .007). Patients were less likely to travel to hospitals deemed to have inadequate care by the national quality regulator (odds ratio, 0.70; 95% CI, 0.50-0.97; P = .03). Patients were not more likely to travel to hospitals with better 2-year bowel cancer mortality outcomes. Conclusions and Relevance Patients appear responsive to hospital characteristics that reflect overall hospital quality and the availability of robotic surgery but not to specific disease-related outcome measures. Policies allowing patients to choose where they have colorectal cancer surgery may not result in better outcomes but could drive inequities in the health care system.
Collapse
Affiliation(s)
- Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Lu Han
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jemma Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Daniel Lewis
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angela Kuyruba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Michael Braun
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom,School of Medical Sciences, University of Manchester, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Nicola Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Richard Sullivan
- Institute of Cancer Policy, King’s College London, London, United Kingdom,Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
13
|
Watanaskul S, Schwab ME, Chern H, Varma M, Sarin A. Robotic transanal excision of rectal lesions: expert perspective and literature review. J Robot Surg 2022; 17:619-627. [PMID: 36244050 PMCID: PMC10076353 DOI: 10.1007/s11701-022-01469-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
AbstractTransanal excision of benign lesions, moderately or well-differentiated rectal T1 adenocarcinomas is typically completed via transanal endoscopic microsurgery (TEM) or laparoscopic transanal minimally invasive surgery (TAMIS). Robotic platforms provide ergonomic comfort in an enclosed space, enhanced range of motion, and superior 3D visualization. This study sought to perform a literature review of robotic TAMIS (R-TAMIS) and provide expert commentary on the technique. A Pubmed literature search was performed. Study design, robot type, indication, techniques compared, surgical margins, conversion, complications, operative time, estimated blood loss, patient positioning, and defect closure were collected from included articles. Expert opinion on pre-operative planning, technical details, and possible pitfalls was provided, with an accompanying video. Twelve articles published between 2013 and 2022 were included. Five were case reports, three case series, two prospective cohort studies, one retrospective cohort study, and one Phase II trial. The Da Vinci Si (n = 3), Xi (n = 2), single port (n = 3) and flex robotic system (n = 2) were used. Five studies reported negative surgical margins, one reported positive margins, and six did not comment. Operating room time ranged from 45 to 552 min and EBL ranged from 0 to 100 mL. Patient positioning varied based on lesion location but included supine, prone, modified lithotomy, and prone jackknife positions. 11/12 studies reported defect closure, most commonly with V-Loc absorbable suture. We recommend pre-operative MRI abdomen/pelvis, digital rectal exam, and rigid proctoscopy; prone jackknife patient positioning to avoid collisions with robotic arms; and defect closure of full-thickness excisions with backhanded running V-Loc suture.
Collapse
Affiliation(s)
- Sarah Watanaskul
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Marisa E Schwab
- Department of Surgery, University of California San Francisco, 550 16th Street, San Francisco, CA, 94143, USA.
| | - Hueylan Chern
- Department of Surgery, University of California San Francisco, 550 16th Street, San Francisco, CA, 94143, USA
| | - Madhulika Varma
- Department of Surgery, University of California San Francisco, 550 16th Street, San Francisco, CA, 94143, USA
| | - Ankit Sarin
- Department of Surgery, University of California San Francisco, 550 16th Street, San Francisco, CA, 94143, USA
| |
Collapse
|
14
|
Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era. Dis Colon Rectum 2022; 65:1025-1033. [PMID: 34897209 DOI: 10.1097/dcr.0000000000002109] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings. OBJECTIVE The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis. DESIGN This was a retrospective analysis study. SETTINGS Data were collected from the American College of Surgeons National Quality Improvement Program database. PATIENTS All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included. MAIN OUTCOME MEASURES Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery. RESULTS A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p < 0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p < 0.0001) and emergent (0% in 2005 to 42% in 2018; p < 0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization. LIMITATIONS This study was limited by its retrospective nature of the analysis. CONCLUSION Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 . CIRUGA DE URGENCIA Y EMERGENCIA PARA LA COLITIS ULCEROSA EN LOS ESTADOS UNIDOS EN LA ERA MNIMAMENTE INVASIVA Y DE TERAPIA BIOLGICA ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p <0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p <0,0001) y emergentes (0% en 2005 a 42% en 2018; p <0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).
Collapse
|
15
|
Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery. Am J Surg 2022; 224:757-760. [DOI: 10.1016/j.amjsurg.2022.04.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/11/2022] [Accepted: 04/30/2022] [Indexed: 11/19/2022]
|
16
|
McKenna NP, Bews KA, Cima RR, Crowson CS, Habermann EB. Validation of a left-sided colectomy anastomotic leak risk score and assessment of diversion practices. Am J Surg 2022; 224:971-978. [DOI: 10.1016/j.amjsurg.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
|
17
|
Hahn SJ, Sylla P. Technological Advances in the Surgical Treatment of Colorectal Cancer. Surg Oncol Clin N Am 2022; 31:183-218. [DOI: 10.1016/j.soc.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
18
|
Horsey ML, Lai D, Sparks AD, Herur-Raman A, Borum M, Rao S, Ng M, Obias VJ. Disparities in utilization of robotic surgery for colon cancer: an evaluation of the U.S. National Cancer Database. J Robot Surg 2022; 16:1299-1306. [DOI: 10.1007/s11701-022-01371-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/09/2022] [Indexed: 12/15/2022]
|
19
|
Justiniano CF, Becerra AZ, Loria A, Xu Z, Aquina CT, Temple LK, Fleming FJ. Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence. Surg Endosc 2022; 36:5618-5626. [PMID: 35024928 PMCID: PMC8757409 DOI: 10.1007/s00464-022-09023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
Background It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery. Methods The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression. Results Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47–61%, p < 0.0001). For colectomy, overall minimally invasive-surgery rates increased (54–66%, p < 0.0001), laparoscopic remained stable (53–54%), and robotics increased (1–12%). For proctectomy, overall minimally invasive-surgery rates increased (22–43%, p < 0.0001), laparoscopic remained stable (20–21%), and robotics increased (2–22%). Over the study period, 2487 surgeons performed colectomies. Among 156 surgeons with IRU for colectomies, robotics increased (2–29%), while laparoscopy decreased (67–44%), and open surgery decreased (31–27%). Overall, surgeons with IRU performed minimally invasive colectomies 73% of the time in 2015 versus 69% in 2009. Over the study period, 1131 surgeons performed proctectomies. Among 94 surgeons with IRU for proctectomies, robotics increased (3–42%), while laparoscopy decreased (25–15%), and open surgery decreased (73–44%). Overall, surgeons with IRU performed minimally invasive proctectomy 56% of the time in 2015 versus 27% in 2009. Patients in the latter study period had 57% greater odds of undergoing robotic surgery. Conclusions Overall, minimally invasive colorectal resections increased from 2009 to 2015 largely due to increasing robotic utilization, particularly for proctectomies.
Collapse
Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA.
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony Loria
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Zhaomin Xu
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State Medical Center, Columbus, OH, USA
| | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| |
Collapse
|
20
|
OUP accepted manuscript. Br J Surg 2022; 109:763-771. [DOI: 10.1093/bjs/znac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 11/14/2022]
|
21
|
Dhanani NH, Olavarria OA, Bernardi K, Lyons NB, Holihan JL, Loor M, Haynes AB, Liang MK. The Evidence Behind Robot-Assisted Abdominopelvic Surgery : A Systematic Review. Ann Intern Med 2021; 174:1110-1117. [PMID: 34181448 DOI: 10.7326/m20-7006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Use of robot-assisted surgery has increased dramatically since its advent in the 1980s, and nearly all surgical subspecialties have adopted it. However, whether it has advantages compared with laparoscopy or open surgery is unknown. PURPOSE To assess the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults. DATA SOURCES PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2021. STUDY SELECTION Randomized controlled trials that compared robot-assisted abdominopelvic surgery with laparoscopy, open surgery, or both. DATA EXTRACTION Two reviewers independently extracted study data and risk of bias. DATA SYNTHESIS A total of 50 studies with 4898 patients were included. Of the 39 studies that reported incidence of Clavien-Dindo complications, 4 (10%) showed fewer complications with robot-assisted surgery. The majority of studies showed no difference in intraoperative complications, conversion rates, and long-term outcomes. Overall, robot-assisted surgery had longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery. LIMITATIONS Heterogeneity was present among and within the included surgical subspecialties, which precluded meta-analysis. Several trials may not have been powered to assess relevant differences in outcomes. CONCLUSION There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes without the existing disadvantages. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42020182027).
Collapse
Affiliation(s)
- Naila H Dhanani
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Oscar A Olavarria
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Karla Bernardi
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Nicole B Lyons
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Julie L Holihan
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Michele Loor
- Baylor College of Medicine, Houston, Texas (M.L.)
| | - Alex B Haynes
- Dell Medical School at the University of Texas, Austin, Texas (A.B.H.)
| | - Mike K Liang
- University of Houston, HCA Kingwood, Kingwood, Texas (M.K.L.)
| |
Collapse
|
22
|
Initial experience with a suprapubic single-port robotic right hemicolectomy in patients with colon cancer. Tech Coloproctol 2021; 25:1065-1071. [PMID: 34156568 DOI: 10.1007/s10151-021-02482-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND We developed a novel suprapubic single-port robotic right hemicolectomy (spRHC) procedure for patients with right colon cancer using a da Vinci SP Surgical System. The aim of this study was to determine the safety and feasibility of this technique. METHODS We performed the spRHC procedure on five patients with right colon cancers between July and September 2020. All procedures including colon mobilization, D3 lymphadenectomy, and intracorporeal anastomosis were completed using the single-port robotic platform through a mini-transverse suprapubic incision and an additional assistant port. Data regarding patient characteristics, perioperative outcomes and pathologic results were analyzed. RESULTS Four of the five patients were males. The median age was 69 years (range, 58-77 years).Two patients received preoperative chemotherapy for advanced colon cancer. The median total operative time was 160 min (range, 150-240 min). The median docking time was 4 min 40 s (range, 2 min 10 s-5 min 10 s). The median console time was 105 min (range, 100-120 min). There were no conversions to multiport or open surgeries. The median hospital stay was 7 days (range, 5-12 days). One patient experienced a wound infection. The median number of harvested lymph nodes was 41 (range, 39-50 lymph nodes). CONCLUSIONS SpRHC is safe and feasible. However, further comparative studies are needed to assess whether this procedure can provide patients with significant benefits compared with multiport robotic surgery.
Collapse
|
23
|
Stundner O, Zubizarreta N, Mazumdar M, Memtsoudis SG, Wilson LA, Ladenhauf HN, Poeran J. Differential Perioperative Outcomes in Patients With Obstructive Sleep Apnea, Obesity, or a Combination of Both Undergoing Open Colectomy: A Population-Based Observational Study. Anesth Analg 2021; 133:755-764. [PMID: 34153009 DOI: 10.1213/ane.0000000000005638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND An increasing body of evidence demonstrates an association between obstructive sleep apnea (OSA) and adverse perioperative outcomes. However, large-scale data on open colectomies are lacking. Moreover, the interaction of obesity with OSA is unknown. This study examines the impact of OSA, obesity, or a combination of both, on perioperative complications in patients undergoing open colectomy. We hypothesized that while both obesity and OSA individually increase the likelihood for perioperative complications, the overlap of the 2 conditions is associated with the highest risk. METHODS Patients undergoing open colectomies were identified using the national Premier Healthcare claims-based Database (2006-2016; n = 340,047). Multilevel multivariable models and relative excess risk due to interaction (RERI) analysis quantified the impact of OSA, obesity, or both on length and cost of hospitalization, respiratory and cardiac complications, intensive care unit (ICU) admission, mechanical ventilation, and inhospital mortality. RESULTS Nine thousand twenty-eight (2.7%) patients had both OSA and obesity diagnoses; 10,137 (3.0%) had OSA without obesity; and 33,692 (9.9%) had obesity without OSA. Although there were overlapping confidence intervals in the binary outcomes, the risk increase was found highest for OSA with obesity, intermediate for obesity without OSA, and lowest for OSA without obesity. The strongest effects were seen for respiratory complications: odds ratio (OR), 2.41 (2.28-2.56), OR, 1.40 (1.31-1.49), and OR, 1.50 (1.45-1.56), for OSA with obesity, OSA without obesity, and obesity without OSA, respectively (all P < .0001). RERI analysis revealed a supraadditive effect of 0.51 (95% confidence interval [CI], 0.34-0.68) for respiratory complications, 0.11 (-0.04 to 0.26) for cardiac complications, 0.30 (0.14-0.45) for ICU utilization, 0.34 (0.21-0.47) for mechanical ventilation utilization, and 0.26 (0.15-0.37) for mortality in patients with both OSA and obesity, compared to the sum of the conditions' individual risks. Inhospital mortality was significantly higher in patients with both OSA and obesity (OR [CI], 1.21 [1.07-1.38]) but not in the other groups. CONCLUSIONS Both OSA and obesity are individually associated with adverse perioperative outcomes, with a supraadditive effect if both OSA and obesity are present. Interventions, screening, and perioperative precautionary measures should be tailored to the respective risk profile. Moreover, both conditions appear to be underreported compared to the general population, highlighting the need for stringent perioperative screening, documentation, and reporting.
Collapse
Affiliation(s)
- Ottokar Stundner
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology and Critical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Nicole Zubizarreta
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology & Public Health, Weill Cornell Medical College, New York, New York.,Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Hannah N Ladenhauf
- Department of Pediatric and Adolescent Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Departments of Orthopaedic Surgery, Population Health Science & Policy, and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
24
|
Quilici PJ, Wolberg H, McConnell N. Operating costs, fiscal impact, value analysis and guidance for the routine use of robotic technology in abdominal surgical procedures. Surg Endosc 2021; 36:1433-1443. [PMID: 33835252 DOI: 10.1007/s00464-021-08428-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study was designed to define the value, cost, and fiscal impact of robotic-assisted procedures in abdominal surgery and provide clinical guidance for its routine use. METHODS 34,984 patients who underwent an elective cholecystectomy, colectomy, inguinal hernia repair, hysterectomy, or appendectomy over a 24-month period were analyzed by age, BMI, risk class, operating time, LOS and readmission rate. Average Direct and Total Cost per Case (ADC, TCC) and Net Margin per Case (NM) were produced for each surgical technique, i.e., open, laparoscopic, and robotic assisted (RA). RESULTS All techniques were shown to have similar clinical outcomes. 9412 inguinal herniorrhaphy were performed (48% open with $2138 ADC, 29% laparoscopy with $3468 ADC, 23% RA with $6880 ADC); 8316 cholecystectomies (94% laparoscopy with $2846 ADC, 4.4% RA with a $7139 ADC, 16% open with a $3931 ADC); 3432 colectomies (42% open with a $12,849 ADC, 38% laparoscopy with a $10,714, 20% RA with a $15,133); 12,614 hysterectomies [42% RA with a $8213 Outpatient (OP) ADC, 39% laparoscopy $5181 OP ADC, 19% open $4894 OP ADC]. Average Global NM is - 1% for RA procedures and only positive with commercial payors. CONCLUSION RA techniques do not produce significant clinical enhancements than similar surgical techniques with identical outcomes while their costs are much higher. The produced value analysis does not support the routine use of RA techniques for inguinal hernia repair and cholecystectomy. RA techniques for hysterectomies and colectomies are also performed at much higher cost than open and laparoscopic techniques, should only be routinely used with appropriate clinical justification and by cost efficient surgical providers.
Collapse
Affiliation(s)
- Philippe J Quilici
- PSJH System Digestive Health Institute, Renton, WA, USA. .,PSJMC MIS-Ba Service, Burbank, CA, USA.
| | | | | |
Collapse
|
25
|
Mazer L, Varban O, Montgomery JR, Awad MM, Schulman A. Video is better: why aren't we using it? A mixed-methods study of the barriers to routine procedural video recording and case review. Surg Endosc 2021; 36:1090-1097. [PMID: 33616730 DOI: 10.1007/s00464-021-08375-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/09/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Video-based case review for minimally invasive surgery is immensely valuable for education and quality improvement. Video review can improve technical performance, shorten the learning curve, disseminate new procedures, and improve learner satisfaction. Despite these advantages, it is underutilized in many institutions. So far, research has focused on the benefits of video, and there is relatively little information on barriers to routine utilization. METHODS A 36-question survey was developed on video-based case review and distributed to the SAGES email list. The survey included closed and open-ended questions. Numeric responses and Likert scales were compared with t-test; open-ended responses were reviewed qualitatively through rapid thematic analysis to identify themes and sub-themes. RESULTS 642 people responded to the survey for a response rate of 11%. 584 (91%) thought video would improve the quality of educational conferences. 435 qualitative responses on the value of video were analyzed, and benefits included (1) improved understanding, (2) increased objectivity, (3) better teaching, and (4) better audience engagement. Qualitative comments regarding specific barriers to recording and editing case video identified challenges at all stages of the process, from (1) the decision to record a case, (2) starting the recording in the OR, (3) transferring and storing files, and (4) editing the file. Each step had its own specific challenges. CONCLUSION Minimally invasive surgeons want to increase their utilization of video-based case review, but there are multiple practical challenges to overcome. Understanding these barriers is essential in order to increase use of video for education and quality improvement.
Collapse
Affiliation(s)
- Laura Mazer
- Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Oliver Varban
- Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - John R Montgomery
- Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Michael M Awad
- Department of Surgery, Division of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, USA
| | - Allison Schulman
- Department of Gastroenterology, Division of Interventional Gastroenterology, University of Michigan, Ann Arbor, USA
| |
Collapse
|
26
|
Grass F, Merchea A, Mathis KL, Mishra N, Heien H, Sangaralingham LR, Larson DW. Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer. J Surg Oncol 2021; 123:1023-1029. [PMID: 33497477 DOI: 10.1002/jso.26390] [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: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
Collapse
Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Switzerland
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Herbert Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
27
|
Worldwide diffusion of robotic approach in general surgery. Updates Surg 2021; 73:795-797. [PMID: 33389652 DOI: 10.1007/s13304-020-00914-3] [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: 06/25/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
The robotic system has overcome some laparoscopic shortcomings, such as stereoscopic 3D-magnified vision, a stable camera and flexible and tremor filtering manipulation. Therefore, robotic surgery has made many steps forward gaining more diffusion in the field of general surgery and this trend was associated with a decrease in laparoscopic surgery. Although the safety and effectiveness of robotic surgical systems in most procedures has been confirmed, some difficult procedures have not been widely performed but rather limited to a few highly specialized centers. This study describes the worldwide diffusion of robotic surgery in their respective fields in terms of hepatectomy, gastrectomy, esophagectomy, colectomy and pancreatectomy, respectively. The worldwide diffusion of robotic surgery is uneven, which may be related to the local economic strength, government health care policies, and surgeons' preference for minimally invasive surgery of various countries and regions. In the future, with the gradual decrease of cost of robotic surgical systems, and the standardization of surgical procedures, as well as the coverage of medical insurance, we believe that robotic surgery will become the gold standard procedure in general surgery.
Collapse
|
28
|
Trends of complications and innovative techniques' utilization for colectomies in the United States. Updates Surg 2020; 73:101-110. [PMID: 32772277 DOI: 10.1007/s13304-020-00862-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
Abstract
Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay.
Collapse
|
29
|
Raj R, Seppä K, Luostarinen T, Malila N, Seppälä M, Pitkäniemi J, Korja M. Disparities in glioblastoma survival by case volume: a nationwide observational study. J Neurooncol 2020; 147:361-370. [PMID: 32060840 PMCID: PMC7136186 DOI: 10.1007/s11060-020-03428-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
Introduction High hospital case volumes are associated with improved treatment outcomes for numerous diseases. We assessed the association between academic non-profit hospital case volume and survival of adult glioblastoma patients. Methods From the nationwide Finnish Cancer Registry, we identified all adult (≥ 18 years) patients with histopathological diagnoses of glioblastoma from 2000 to 2013. Five university hospitals (treating all glioblastoma patients in Finland) were classified as high-volume (one hospital), middle-volume (one hospital), and low-volume (three hospitals) based on their annual numbers of cases. We estimated one-year survival rates, estimated median overall survival times, and compared relative excess risk (RER) of death between high, middle, and low-volume hospitals. Results A total of 2,045 patients were included. The mean numbers of annually treated patients were 54, 40, and 17 in the high, middle, and low-volume hospitals, respectively. One-year survival rates and median survival times were higher and longer in the high-volume (39%, 9.3 months) and medium-volume (38%, 8.9 months) hospitals than in the low-volume (32%, 7.8 months) hospitals. RER of death was higher in the low-volume hospitals than in the high-volume hospital (RER = 1.19, 95% CI 1.07–1.32, p = 0.002). There was no difference in RER of death between the high-volume and medium-volume hospitals (p = 0.690). Conclusion Higher glioblastoma case volumes were associated with improved survival. Future studies should assess whether this association is due to differences in patient-specific factors or treatment quality. Electronic supplementary material The online version of this article (10.1007/s11060-020-03428-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, P.O. Box 266, 00029, Helsinki, Finland
| | - Karri Seppä
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, 00130, Helsinki, Finland
| | - Tapio Luostarinen
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, 00130, Helsinki, Finland
| | - Nea Malila
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, 00130, Helsinki, Finland
| | - Matti Seppälä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, P.O. Box 266, 00029, Helsinki, Finland
| | - Janne Pitkäniemi
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, 00130, Helsinki, Finland.,School of Social Sciences, Tampere University, Tampere, Finland.,Department of Public Health, School of Medicine, University of Helsinki, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, P.O. Box 266, 00029, Helsinki, Finland.
| |
Collapse
|