Predicting conversion in laparoscopic colorectal surgery. Fellowship training may be an advantage

Factors associated with conversion in laparoscopic surgery in a low-resource setting: a single-center prospective study

INTRODUCTION

Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting.

METHODS

This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate.

RESULTS

A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11-75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1-16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002).

CONCLUSION

A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings.

The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus

The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognized to be steep however it is poorly defined in the literature. This study is a retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction, and complication rates. Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.

Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study

BACKGROUND

Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes.

METHODS

This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses.

RESULTS

Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p =  < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8 days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70 min and LOS of 13.3 days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56 min and LOS of 15 days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04).

CONCLUSION

Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.

What influences conversion to open surgery during laparoscopic colorectal resection?

INTRODUCTION

We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques.

METHODS

We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x² and t tests and used the Bonferroni Correction to account for multiple statistical testing.

RESULTS

From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups.

CONCLUSIONS

Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

Surgical teaching does not increase the risk of intraoperative adverse events

INTRODUCTION

Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees.

METHODS

Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups.

RESULTS

Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788).

CONCLUSION

Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.

Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery

AIM

The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery.

METHOD

An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C).

RESULTS

In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity.

CONCLUSION

Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.

Conversions in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery offers patients with rectal cancer short-term benefits and similar survival rates as open surgery. However, selecting patients who are suitable candidates for laparoscopic surgery is essential to prevent intra-operative conversion from laparoscopic to open surgery. Clinical and pathological variables were studied among patients who had converted laparoscopic surgeries within the COLOR II trial to improve patient selection for laparoscopic rectal cancer surgery.

METHODS

Between January 20, 2004, and May 4, 2010, 1044 patients with rectal cancer enrolled in the COLOR II trial and were randomized to either laparoscopic or open surgery. Of 693 patients who had laparoscopic surgery, 114 (16 %) were converted to open surgery. Predictive factors were studied using multivariate analyses, and morbidity and mortality rates were determined.

RESULTS

Factors correlating with conversion were as follows: age above 65 years (OR 1.9; 95 % CI 1.2-3.0: p = 0.003), BMI greater than 25 (OR 2.7; 95 % CI 1.7-4.3: p < 0.001), and tumor location more than 5 cm from the anal verge (OR 0.5; CI 0.3-0.9). Gender was not significantly related to conversion (p = 0.14). In the converted group, blood loss was greater (p < 0.001) and operating time was longer (p = 0.028) compared with the non-converted laparoscopies. Hospital stay did not differ (p = 0.06). Converted procedures were followed by more postoperative complications compared with laparoscopic or open surgery (p = 0.041 and p = 0.042, respectively). Mortality was similar in the laparoscopic and converted groups.

CONCLUSIONS

Age above 65 years, BMI greater than 25, and tumor location between 5 and 15 cm from the anal verge were risk factors for conversion of laparoscopic to open surgery in patients with rectal cancer.

The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

AIM

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

METHOD

A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined.

RESULTS

Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time.

CONCLUSION

Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.

Outreach training model for accredited colorectal specialists in laparoscopic colorectal surgery: feasibility and evaluation of challenges

AIM

The aim of this study was to explore the feasibility and safety of an outreach model of laparoscopic colorectal training of accredited specialists in advanced laparoscopic techniques and to explore the challenges of this model from the perspective of a National Training Programme (NTP) trainer.

METHOD

Prospective data were collected for unselected laparoscopic colorectal training procedures performed by five laparoscopic colorectal NTP trainees supervised by a single NTP trainer with an outreach model between 2009 and 2012. The operative and postoperative outcomes were compared with standard laparoscopic colorectal training procedures performed by six senior colorectal trainees under the supervision of the same NTP trainer within the same study period. The primary outcome was 30-day mortality. The Mann-Whitney test was used to compare continuous variables and the Chi squared or Fisher's exact tests were applied for the analysis of categorical variables. The level of statistical significance was set at P < 0.05.

RESULTS

During the study period 179 elective laparoscopic colorectal procedures were performed. This included 54 cases performed by NTP trainees and 125 cases performed by the supervised trainees. There were no significant differences in age, gender, body mass index, American Society of Anesthesiologists grade, pathology and procedure type between both groups. Seventy-eight per cent of the patients operated on by the NTP trainees had had no previous abdominal surgery, compared with 50% in the supervised trainees' group (P = 0.0005). There were no significant differences in 30-day mortality or the operative and postoperative outcome between both groups. There were, however, difficulties in training an already established consultant in his or her own hospital and these were overcome by certain adjustments to the programme.

CONCLUSION

Outreach laparoscopic training of colorectal surgeons is a feasible and safe model of training accredited specialists and does not compromise patient care. The challenges encountered can be overcome with optimum training and preparation.

Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes

Background

The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.

Methods

A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis.

Results

Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0·86, 95 per cent c.i. 0·84 to 0·88), as was the rate of complications (odds ratio 0·90, 0·78 to 1·02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1·04, 95 per cent c.i. 1·03 to 1·05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1·00, 1·00 to 1·01), complications (RR 1·03, 0·98 to 1·08) or conversion to open surgery (RR 1·01, 1·00 to 1·01).

Conclusion

Fellowship training appears to have a positive impact on patient outcomes.

Technique of last resort: characteristics of patients undergoing open surgery in the laparoscopic era

BACKGROUND

The utilization rates for minimally invasive colorectal resection techniques (MICR) continue to increase. In some centers MICR methods are the preferred approach, however, open methods continue to be utilized for select patients. In this study, the profile and short-term outcomes of open colorectal resection (CR) and MICR patients are determined and compared.

METHODS

A retrospective review of patients who underwent elective CR over 11 years at two institutions was performed. The MICR group contained both laparoscopic-assisted and hand-assisted cases. The past medical and surgical histories, indications, operations performed, and short-term outcomes were assessed. The Charlson co-morbidity index (CMI) was used to assess risk.

RESULTS

During the study period 1080 patients underwent CR (Open, 141; MICR, 939). As judged by the CMI, there were more high-risk patients (score ≥2) in the Open group (34.38%) versus MICR (22.11%) p = 0.0029. Significantly more open patients had prior abdominal surgery and specifically CRs (Open, 15.60% vs. MICR, 2.13%, p < 0.001). Intraoperative transfusion (Open 25.7%; MICR 6.8%, p < 0.001) and diversion (25.53 vs. 11.50%, p < 0.001) were more common in the Open group. Not surprisingly, recovery of bowel function and length of stay were longer for the Open group. The overall complication rate was also higher for the Open patients (p < 0.001).

CONCLUSION

When MICR is the procedure of choice, patients selected for Open CR are higher risk and more complex as judged by the CMI and past operative history. Not surprisingly, this translates into a longer length of stay, higher rates of transfusion, diversion, and complications. This disparity in patients undergoing CRs makes direct comparison of MICR and Open resection outcomes not reasonable.

Is competency assessment at the specialist level achievable? A study for the national training programme in laparoscopic colorectal surgery in England

OBJECTIVES

To develop, validate, and implement a competency assessment tool (CAT) for technical surgical performance in the context of a summative assessment process for the National Training Programme in Laparoscopic Colorectal Surgery (NTP).

BACKGROUND

The NTP is an educational initiative by the National Cancer Action Team in England to safely increase the uptake of laparoscopic colorectal surgery. It is the first competency-based national educational initiative for specialist surgeons (consultants), and performance assessment is an integral part of the program.

METHODS

Content validity was sought using expert opinion by semistructured interviews and the Delphi method. For validity and reliability studies, NTP apprentices and experts were asked to submit video-recorded cases. Construct validity was established between delegates who passed the assessment and those who failed. Concurrent validity was tested by comparing scores with error counts as identified by observational clinical human reliability analysis. A fully crossed design, using generalizability theory methods and D-studies, was used for reliability.

FINDINGS

Interviews and the Delphi method revealed a list of characteristics for assessment. A hybrid structure combining task-specific and generic items was used to include important characteristics into the assessment format. Fifty-four cases were submitted. Overall reliability reached G(ACI) = 0.803 when using 2 cases and 2 assessors. Experts scored significantly better than apprentices (3.19 vs 2.60; P = 0.004), and apprentices who passed had better scores than those who failed (2.95 vs 2.28; P < 0.001). There was an inverse correlation between CAT scores and observational clinical human reliability analysis error counts (ρ = -0.520, P < 0.001). The combination of both methods reached overall sensitivity of 100%, specificity of 83.3%, a positive predictive value of 93.8%, and a negative predictive value of 100%.

CONCLUSIONS

The CAT can reliably assess technical performance in laparoscopic colorectal surgery. The use of CATs to judge specialist technical performance before embarking on independent practice of new procedures is achievable on a national scale and can be adapted by other specialties.

Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases

BACKGROUND

The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available.

OBJECTIVE

The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice.

DATA SOURCES

Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed.

STUDY SELECTION

Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected.

INTERVENTION

No interventions were performed.

MAIN OUTCOME MEASURES

Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process.

RESULTS

Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed.

LIMITATIONS

The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve

CONCLUSIONS

This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.

Body surface area: a new predictor factor for conversion and prolonged operative time in laparoscopic colorectal surgery

BACKGROUND

Body surface area is a measurement of body size used in clinical settings. Its impact on laparoscopic colorectal surgery has not been previously studied.

OBJECTIVE

The aim of this study was to assess the impact of body surface area on the conversion rate and laparoscopic operative time.

DESIGN

This study was conducted as a retrospective analysis of prospectively collected data.

SETTING

This study was conducted at a single tertiary care institution.

PATIENTS

Nine hundred sixteen consecutive patients operated on between January 2004 and August 2011 were identified from a prospective database.

MAIN OUTCOME MEASURES

Conversion rate and laparoscopic operative time were analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area; body surface area was calculated by the Mosteller formula. Body surface area was analyzed by the use of median and quartile cutoff values (1.6, 1.8, and 2.0). Multivariate models were adjusted for different confounders. Interaction between body surface area and BMI was ruled out.

RESULTS

The conversion rate was 10%. Conversion rates for quartiles 1, 2, 3, and 4 were 4.4%, 8.3%, 12.7%, and 14.8%, p = 0.001. Patients with body surface area ≥ 1.8 had a higher conversion rate than those with body surface area <1.8 (13.9% vs 5.3%, OR: 2.35 (95% CI: 1.45-3.86; p = 0.0001)). Multivariate analysis showed that body surface area ≥ 1.8 was associated with conversion (OR: 2, 95% CI: 1.1-3.7, p = 0.02) and a longer operative time after adjusting for sex, age, obesity, disease location (rectum vs colon), and type of laparoscopic approach.

LIMITATION

This was a single-institution retrospective study.

CONCLUSION

Body surface area is a predictor for conversion and longer laparoscopic operative time. It should be considered when informing patients, selecting cases in the early learning curve, and assessing standard of care.

'Trainee' evaluation of the English National Training Programme for laparoscopic colorectal surgery

AIM

The aim of this study was to review trainees' opinions of the training they had received through the National Training Programme (NTP).

METHOD

An online questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Percentages, mean values and SD were presented. ANOVA and Mann-Whitney U-tests were used to examine the impact of different factors on ratings and the difference between ratings, respectively.

RESULTS

Fifty-four registered trainees fulfilled the inclusion criteria, and 37 (69% response rate) completed the questionnaire. Teaching sessions were organized using an inreach (11%), in-house (11%), outreach (27%) or combination (51%) system of training. Trainees felt that their trainers seldom cancelled sessions (93%), that it was easy to organize (92%) and consent (100%) the patient, and that their hospital was supportive of training (97%). Trainees stated that overall their trainers were excellent at training (Likert scale = 4.71 ± 0.46) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer P = 0.050; critical of NTP, chose trainer P = 0.020).

CONCLUSION

The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.

Surgical fellowship training in Canada: what is its current status and is improvement required?

This paper examines current issues concerning surgical fellowship training in Canada. Other than information from a few studies of fellowship training in North America, there are scant data on this subject in the literature. Little is known about the demographic characteristics of those who pursue fellowship training in Canada, what the experiences and expectations are of fellows and their supervisors with respect to the strengths and weaknesses of this level of training, or how this level of education fits in with Canadian undergraduate and postgraduate medical training. We summarize current knowledge about fellowship training in Canada as it pertains to demographic characteristics, finances, work hours, residency training, preparation for clinical and research work and satisfaction with training. Most information on surgical fellowship training comes from the United States. As such, we used information from American studies to supplement the Canadian data. Because a surgical fellowship experience in Canada may be different from that in the United States, we propose that Canadian surgical fellows and their supervisors should be surveyed to gain an understanding of such information. This knowledge could be used to improve surgical fellowship training in Canada.

The impact of obesity on perioperative outcomes after laparoscopic colorectal resection

OBJECTIVE

It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients.

METHODS

We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles.

RESULTS

A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients.

CONCLUSIONS

Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

Is there a learning curve in foot and ankle surgery?

BACKGROUND

Previous studies of orthopaedic learning curves have largely described the introduction of new techniques to experienced consultants. End points have usually involved technical considerations. A paucity of evidence surrounds foot and ankle surgery. This study investigates the learning curve during a foot and ankle surgeon's first year, defined by functional outcome.

METHODS

150 patients underwent elective foot or ankle surgery during the whole period. Preoperative and 6 month postoperative functional scores were compared between the first and second 6 month groups.

RESULTS

Functional improvement was greater, approaching significance, in the second group (p=0.0605). There was no difference for forefoot cases (p=0.345). Functional improvement was significantly greater in the second group with forefoot cases removed (p=0.0333).

CONCLUSIONS

A learning curve exists in the first year of practice of foot and ankle surgery, demonstrated by functional outcome. This is confined to ankle, hindfoot and midfoot, but not forefoot surgery.

Learning curves in laparoscopic right-sided colon cancer surgery: a comparison of first-generation colorectal surgeon to advance laparoscopically trained surgeon

BACKGROUND

We aimed to evaluate the learning curve (LC) for laparoscopic right-sided colon cancer surgery (LRCCS) by comparing the results between two surgeons (first-generation colorectal surgeon versus laparoscopically trained surgeon).

METHODS

The study was a retrospective analysis that evaluated 117 consecutive LRCCSs performed by two surgeons, the first-generation surgeon (Surgeon A) and laparoscopically trained surgeon (Surgeon B), from April 1995 to August 2006. Patients were divided into two groups; patients included in groups I and II received LRCCSs from surgeons A and B, respectively.

RESULTS

The moving average method revealed that the operation times of surgeons A and B began to shorten after the 9th case. The cumulative sum (CUSUM) analysis of group I data showed that the 24th case was the peak point of conversion. The 35th case was the peak for intraoperative complications, and the 17th case was the peak for postoperative complications. There was only one case of conversion in group II. The peak points for inadequate lymph node dissection were the 37th case in group I and the 8th case in group II. The CUSUM analysis for surgeons A and B showed that the 18th case and the 8th case, respectively, were the overall peak points in the failure of LRCCS.

CONCLUSIONS

We suggest that careful observation of a laparoscopic procedure, such as acting as the scope operator for a certain amount of time, may help in shortening the LC of the actual procedure.

Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program

INTRODUCTION

The National Training Program for laparoscopic colorectal surgery (LCS) provides supervised training to colorectal surgeons in England. The purpose of this study was to create, validate, and implement a method for monitoring training progression in laparoscopic colorectal surgery that met the requirements of a good assessment tool.

METHODS

A generic scale for different tasks in LCS was created under the guidance of a national expert group. The scores were defined by the extent to which the trainees were dependent on support (1 = unable to perform, 5 = unaided (benchmark), 6 = proficient). Trainers were asked to rate their trainees after each supervised case; trainees completed a similar self-assessment form. Construct validity was evaluated comparing scores of trainees at different experience levels (1-5, 6-10, 11-15, 16+) using the Wilcoxon signed-rank test and ANOVA. Internal consistency was determined by Crohnbach's alpha, interrater reliability by comparing peer- and self-assessment (interclass correlation coefficient, ICC). Proficiency gain curves were plotted using CUSUM charts.

RESULTS

Analysis included 610 assessments (333 by trainers and 277 by trainees). There was high interrater reliability (ICC = 0.867), internal consistency (α = 0.920), and construct validity [F(3,40) = 6.128, p < 0.001]. Detailed analysis of proficiency gain curves demonstrates that theater setup, exposure, and anastomosis were performed independently after 5 to 15 sessions, and the dissection of the vascular pedicle took 24 cases. Mobilization of the colon and of the splenic/hepatic flexure took more than 25 procedures. Median assessment time was 3.3 (interquartile range (IQR) 1-5) minutes and the tool was accepted as useful [median score 5 of 6 (IQR 4-5)].

DISCUSSION

A valid and reliable monitoring tool for surgical training has been implemented successfully into the National Training Program. It provides a description of an individualized proficiency gain curve in terms of both the level of support required and the competency level achieved.

The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians

BACKGROUND

The influence of obesity on surgical outcomes after laparoscopic colorectal surgery in Asian patients is unclear. The aim of this study was to evaluate the feasibility and safety of laparoscopic surgery in obese Asian patients with colorectal cancer.

METHODS

We retrospectively reviewed the prospectively collected data on 984 consecutive patients who underwent laparoscopic surgery for colorectal cancer between May 2001 and February 2008. Patients were classified according to the categories proposed by the International Obesity Task Force, as Nonobese (body mass index [BMI] < 25.0 kg/m(2)), Obese I (BMI 25.0-29.9 kg/m(2)), and Obese II (BMI > or = 30 kg/m(2)). Surgical outcomes, including open conversion, operation time, postoperative complications, estimated blood loss, and postoperative hospital stay, were compared in Nonobese, Obese I, and Obese II patients.

RESULTS

Of the 984 patients, 645 (65.5%), 312 (31.7%), and 27 (2.7%), were classified as Nonobese, Obese I, and Obese II, respectively. Clinicopathologic characteristics were similar among the three groups. The Obese II group had higher conversion rates (14.8% versus 2.6% and 2.9%, P = 0.001), longer operation time (258 versus 201 and 215 min, P = 0.001), and longer postoperative hospital stay (12.1 versus 9.5 and 9.2 days, P = 0.035) than the Nonobese and Obese I groups. However, the rates of intraoperative events (P = 0.634) and postoperative complications (P = 0.603) were similar in nonobese and obese patients. Independent risk factors for conversion were BMI group and operation type. Obese II patients had an 8.36-fold greater risk of conversion than had Nonobese patients (P = 0.001).

CONCLUSIONS

With sufficient experience, laparoscopic colorectal surgery in obese Asian patients is feasible and safe, offering all the benefits of a minimally invasive approach. Management of Asian colorectal cancer patients with BMI > or = 30 kg/m(2) requires meticulous perioperative care, and colorectal surgeons must be familiar with obesity-related challenges in such patients.

Radical prostatectomy: Hospital volumes and surgical volumes - does practice make perfect?

Background

Between the years 1993 and 2003, more than 140,000 men underwent radical prostatectomy (RP), thus making RP one of the most common treatment options for localized prostate cancer in the United States.

Discussion

Localized prostate cancer treated by RP is one of the more challenging procedures performed by urologic surgeons. Studies suggest a definite learning curve in performing this procedure with optimal results noted after performing >500 RPs. But is surgical volume everything? How do hospital volumes of RP weigh in? Could fellowship training in RP reduce the critical volume needed to reach an 'experienced' level?

Summary

As we continue to glean data as to how to optimize outcomes after RP, we must not only consider surgeon and hospital volumes of RP, but also consider training of the individual surgeon.

Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1,073 patients

BACKGROUND

In laparoscopic operations for rectal carcinoma, only a few multicenter studies of a large number of patients have examined the impact of conversion on outcomes and determined risk factors for conversion. This study was designed to evaluate short-term outcomes and risk factors for conversion to open operation in laparoscopic operations for rectal carcinoma.

STUDY DESIGN

A total of 1,073 patients with carcinoma of the rectum and anus who underwent laparoscopic operations were reviewed retrospectively. Patients were collected from 28 institutions. Patients who required conversion during laparoscopic operation were compared with those with completed laparoscopic resection.

RESULTS

Conversion rate was 7.3% (n = 78), and patients requiring conversion were considerably heavier (mean body mass index 24.6 versus 22.7) and had a substantially higher rate of low anterior resection (94.9% versus 83.5%). Conversion was also associated with longer operation time (median 295 minutes versus 270 minutes), greater blood loss (median 265 mL versus 80 mL), longer median postoperative hospital stay (20 days versus 14 days), and higher rates of intraoperative (32.1% versus 3.5%) and postoperative (43.6% versus 21.1%) complications. In multivariate analysis, body mass index and rate of low anterior resection were predictive of conversion.

CONCLUSIONS

Conversion to open operation is associated with greater morbidity than completed laparoscopic resection. Body mass index and the particular laparoscopic procedure are risk factors for conversion, indicating that appropriate patient selection is essential in laparoscopic operations for rectal carcinoma.

Comparison of conventional and laparoscopic Hartmann's procedure reversal

PURPOSE

This study compares open Hartmann's procedure reversal (OHPR) and laparoscopic Hartmann's procedure reversal (LHPR) in patients first treated for peritonitis (Henchey III or IV).

METHODS

Fourteen patients who underwent LHPR during a 2-year period were compared with 20 patients who had previously undergone an open procedure at the same institution.

RESULTS

Conversion rate was 14.28%. Operating time was shorter for the laparoscopic group [143 (90 to 240) vs. 180 (90 to 350) min, P<0.05]. Hospital length of stay was shorter for the laparoscopic group [9.5 (4 to 18) vs. 11 (6 to 39)]. Use of patient-controlled analgesia was not significantly shorter in the laparoscopic group [3 (0 to 4) vs. 3.5 (0 to 8)]. Morbidities observed in the LHPR group include a parietal abscess and an anastomotic stenosis without surgical treatment. The OHPR group had 6 complications: 1 anastomotic leak and 5 incisional hernias.

CONCLUSIONS

LHPR with a conversion rate of 14.28% seems to be a method with shorter operating time and less morbidity compared with OHPR.

Minimally invasive surgery: the evolution of fellowship

BACKGROUND

The field of postgraduate minimally invasive surgery/gastrointestinal surgery (MIS/GIS) training has undergone substantial growth and change. To determine whether fellowships are meeting a strategic need in training, we conducted a survey to assess the current status and trends of change in MIS/GIS fellowships.

METHODS

A survey was distributed to fellows currently in MIS/GIS programs in the United States and Canada in 2003 and 2006. Fellows were asked to describe demographics as well as their experience both during fellowship and residency. We compared this with aggregate data of resident experience through the Accreditation Council for Graduate Medical Education (ACGME) case logs, data tracked by industry, and program data from the Fellowship Council (FC) web site.

RESULTS

There were 54 responses to the 75 surveys distributed in 2006 (72% response rate). MIS fellows performed more laparoscopic cases during their residency than the average graduating chief resident, but did not feel competent to perform advanced laparoscopic surgery. However, combining fellowship numbers with residency numbers does suggest that the total experience provides competency in a wide variety of procedures.

CONCLUSIONS

It seems that the MIS/GIS Fellowship is meeting a real need among graduating surgical residents; fellows felt unprepared for clinical practice at the completion of residency. It is encouraging to note the improvements in fellowship structure, standards, and overall experience, brought by the efforts of the FC. It is hoped that this report of the state of MIS fellowship with a comprehensive review of current data will aid in further evaluation and improvement.

The impact of obesity on outcome after major colorectal surgery

PURPOSE

There is an epidemic of obesity in the Western world and its associated substantial morbidity and mortality. This review examines the data on the impact of obesity on perioperative morbidity and mortality specifically in the context of colorectal surgery.

METHODS

MEDLINE, PUBMED, and the Cochrane library were searched for relevant articles. A manual search for other pertinent papers also was performed.

RESULTS

There is good evidence that obesity is a risk factor for wound infection after colorectal surgery. Obesity may increase the risk of wound dehiscence, incisional site herniation, and stoma complications. Obesity is linked to anastomotic leak, and obese patient undergoing rectal resections may be at particular risk. There is little data on the impact of obesity on pulmonary and cardiovascular complications after colorectal surgery. Operation times are longer for rectal procedures in obese patients, but hospital stay is not prolonged. Obese patients undergoing laparoscopic colorectal surgery are at increased risk of conversion to an open procedure.

CONCLUSIONS

Obesity has a negative impact on outcome after colorectal surgery. To further clarify the impact of obesity on surgical outcome, it is recommended that future studies examine grades of obesity and include measures of abdominal obesity.

Credentialing for Laparoscopic Bowel Operation: There Is No Substitute for Knowing the Outcomes

BACKGROUND

Case volume and training have been considered as reasonable surrogates for competency that can be used as a basis to grant privileges for performing laparoscopic operations. To determine the validity of this practice, we assessed the relationship of surgical volume and training to provider-related complications after laparoscopic bowel resection.

STUDY DESIGN

All patients undergoing open or laparoscopic resection at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained database. Complications were recorded by a specially trained nurse practitioner and adjudicated monthly by a team of gastrointestinal surgeons. Surgeon case volume, training, and operative indication were assessed for their ability to predict technical complications after laparoscopic resection using a logistic regression model.

RESULTS

Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis.

CONCLUSIONS

Surgeon case volume and training had no relationship to the complication rate after laparoscopic bowel operation. Case selection is a critical confounding variable because surgeons vary so greatly in their indications for using laparoscopic technique. Although documentation of training is appropriately considered in granting privileges, actually tracking outcomes is likely the only reliable way to assess competency.

Predicting conversion to open surgery in laparoscopic left hemicolectomy

PURPOSE

The objective of this study was to quantify the risk of conversion to open surgery of laparoscopic left hemicolectomy at an early stage of the learning curve.

METHODS

A multiple logistic regression analysis of 100 laparoscopic left hemicolectomies completed between April 2001 and May 2004 was performed.

RESULTS

The overall conversion rate was 12%. At univariate analysis, 2 factors were found to be predictive of conversion to open surgery: malignancy (17.2% vs. 5%; P=0.046), and weight level (<60 kg=6.1%; 60 to 90 kg=11.3%; >90 kg=28.6%; P=0.049). At multiple logistic regression, the risk of conversion rose only for patients weighing more than 90 kg.

CONCLUSIONS

On the basis of the results of this study, the surgeon will be able to quantify the risk of conversion to laparotomy with some precision in order to obtain the informed consent of the first 100 patients to whom laparoscopic left hemicolectomy is proposed.

Laparoscopic colon resection for cancer

LAC has become an acceptable alternative in the treatment of colon carcinoma. New data should elucidate better the potential advantages in postoperative recovery, QOL, and cost reduction. Appropriate credentialing for LAC remains essential for widespread application of LAC while preserving patient safety.

Advanced laparoscopic skills acquisition: the case of laparoscopic colorectal surgery

Acquisition of advanced technical skills requires commitment, time, patience, and discipline (eg, the 10-year rule). Dabbling is not a recipe for success. Despite the value of all other teaching methods, guided practice with feedback is essential to develop the high level of visuospatial perceptual ability (observation and performance with feedback) that is necessary for advanced MIS. The necessary ingredients to skill acquisition for advanced MIS procedures (laparoscopic colorectal surgery) for a practicing surgeon include introduction through short courses, access to skill stations, and access to preceptorship or mini-sabbatical. For residents in training, there is no better alternative than an MIS fellowship. In an ideal world where there are enough trainers, the residency environment should provide this training. Comprehensive strategies of knowledge transfer for practicing surgeons should be designed with the input of experts in knowledge transfer.

Survey of minimally invasive surgery fellowship programs

INTRODUCTION

Since there was no accrediting body for minimally invasive surgery fellowships, this investigation was performed to characterize minimally invasive surgery fellowships.

MATERIALS AND METHODS

All minimally invasive surgery fellowships that were noted on the Society of American Gastrointestinal Endoscopic Surgeons website in July 2002 were sent a survey. Only those fellowships that had fellow(s) for the year 2001-2002 were included in the survey. All programs were contacted a second time if the survey was not returned. Incomplete responses were not included in the data.

RESULTS

There were 78 fellowships listed, of which 16 had no fellow in 2001-2002, one which was not a minimally invasive surgery fellowship, and one which was listed twice. Of the 19 (32%) programs that responded, there was an average of 1.3 clinical fellows per program (range, 1-3). All clinical fellowships were of one year duration. There was an average of 3.2 attendings for each program. Thirty-two percent of program directors had attended a laparoscopic fellowship. The average program received 50 applications and interviewed 12 applicants for the year 2001-2002. The average fellow had 14 (range, 0-42) manuscripts, abstracts, and/or presentations either completed or in progress. Average minimally invasive cases performed was bariatric 95, colon 33, solid organ (liver, spleen, kidney, adrenal) 32, antireflux 36, hernia 54, and endoscopy 48. However, the range of these cases varied and the lowest number of cases for each category was bariatric 5, colon 3, solid organ 8, antireflux 1, hernia 6, and endoscopy 0.

CONCLUSION

Minimally invasive surgery fellowships seem to be competitive for surgical residents. These fellowships vary in both research and clinical experience.

Laparoscopic colorectal surgery: learning curve and training implications

AIMS

This paper is a review of experience of laparoscopic colorectal surgery at a district general hospital with particular emphasis on the learning curve and training implications.

METHODS

All patients undergoing colorectal surgery where laparoscopy was attempted between March 1998 and October 2003 were included in this study.

RESULTS

There were 80 patients of which 49 had malignancy. Twenty eight stomas and 52 bowel resections were performed laparoscopically. The conversion rate for bowel resection was 32% (decreasing from 38% to 44% to 22%). This was significant (p = 0.001) when compared with stoma formation (7%). The firm has support from a specialist registrar and staff grade surgeon. In 22% of cases, one of the middle grades was the principal operating surgeon, mainly laparoscopic mobilisation and stoma formation. Only 6% of resections were performed by the middle grades. Conversely, a middle grade was the main operating surgeon in 66% of open resections and 61% of stoma formations during the same period. There were in all two deaths and 14 postoperative complications. All patients who had laparoscopic resections for malignancy had clear resection margins.

CONCLUSION

This audit highlights that there is a long learning curve in laparoscopic colorectal surgery with decrease in conversion rates with increasing experience. There is also a reduction in training opportunities in open surgery during the learning phase of the consultant, although this may be counterbalanced by the exposure to laparoscopic techniques. Laparoscopic colonic mobilisation, as a part of stoma formation, is a good starting point for specialist registrar training.

Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy

PURPOSE

The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy.

METHODS

A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999-June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means +/- standard deviations, and appropriate statistical tests were used.

RESULTS

The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat-type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, US. 3,368 dollars vs. US 3,552 dollars; mean, US 4,003 dollars vs. US 4,037 dollars; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates.

CONCLUSIONS

Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.

Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients

BACKGROUND

This study aimed all develop a mathematical model for predicting the conversion rate for patients undergoing laparoscopic colorectal surgery.

METHOD

This descriptive single-center study used routinely collected clinical data from 1,253 patients undergoing laparoscopic surgery between November 1991 and April 2003. A two-level hierarchical regression model was used to identify patient, surgeon, and procedure-related factors associated with conversion of laparoscopic to open surgery. The model was internally validated and tested using measures of discrimination and calibration. Exclusion criteria for laparoscopic colectomy included a body mass greater than 50, lesion diameter exceeding 15 cm, and multiple prior major laparotomies (exclusive of appendectomy, hysterectomy, and cholecystectomy).

RESULTS

The average conversion rate for the study population was 10.0% (95% confidence interval [CI], 8.3-11.7%). The independent predictors of conversion of laparoscopic to open surgery were the body mass index (odds ratio [OR], 2.1 per 10 Americans Society of Anesthesiology units increase), (ASA) grade 3 or 4, 1 or 2 (OR, 3.2, 5.8), type of resection (low rectal, left colorectal, right colonic vs small/other bowel procedures; OR, 8.82, 4.76, 2.98), presence of intraoperative abscess (OR, 3.60) or fistula (OR, 4.73), and surgeon seniority (junior vs senior staff OR, 1.56). The model offered adequate discrimination (area under receiver operator characteristic curve, 0.74) and excellent agreement (p = 0.384) between observed and model-predicted conversion rates (range of calibration, 3-32% conversion rate).

CONCLUSIONS

Laparoscopic conversion rates are dependent on a multitude of factors that require appropriate adjustment for case mix before comparisons are made between or within centers. The Cleveland Clinic Foundation (CCF) laparoscopic conversion rate model is a simple additive score that can be used in everyday practice to evaluate outcomes for laparoscopic colorectal surgery.