Reduced perioperative death following laparoscopic colorectal resection: results of an international observational study

Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure

BACKGROUND

Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes.

OBJECTIVES

To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023.

SELECTION CRITERIA

We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group.

AUTHORS' CONCLUSIONS

There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.

Colorectal Resection in Transplant Centers Benefits Kidney But Not Pancreas Transplant Recipients

As graft and patient survival rates improve, transplant recipients are likely to undergo colorectal surgery in their lifetime. Current literature on the surgical outcomes of colorectal resection in kidney and pancreas transplant recipients is sparse. This investigation identifies areas of surgical risk for kidney, pancreas, and pancreas-kidney transplant recipients undergoing colorectal resection at transplant and teaching centers. Multivariate logistic regression and linear regression tests computed odds ratios (OR) and coefficients of the linear regression using National Inpatient Sample data from 2005 to 2014 to identify differences in mortality, morbidity, length of stay (LOS), and total hospital charges among people with pancreas transplant alone (PTx), kidney transplant alone (KTx), pancreas and kidney transplant (PKTx), and nontransplant (non-Tx) undergoing colorectal resection in transplant and teaching centers. Of the 2,737,454 individuals who underwent colorectal resection, 138 PTx, 3,874 KTx, 130 PKTx, and 2,733,312 non-Tx met the inclusion criteria. Overall KTx, PTx, and PKTx were not more likely to suffer a mortality. However, PTx were more likely to suffer a mortality in transplant and teaching centers. Overall, PTx and PKTx had significantly higher morbidity odds ratios (PTx OR: 2.268, p  = 0.002; PKTx OR: 2.578, p  < 0.001) along with longer LOS and higher total hospital charges. KTx incurred no increased morbidity risk in transplant centers. Surgeons and transplant recipients should be aware of the increased morbidity and mortality risks when considering colorectal resection at different center types.

Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis

PURPOSE

The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA).

METHODS

MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model.

RESULTS

Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes.

CONCLUSIONS

Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.

Procedural Risks of Carotid Intervention in 19,000 Patients

BACKGROUND

Randomized controlled trials (RCTs) show that carotid endarterectomy (CEA) and carotid stenting (CAS) reduce long-term stroke risk in symptomatic and asymptomatic patients with carotid artery stenosis. Historical RCTs may not represent contemporary practice and administrative datasets may estimate procedural risks more reliably. We studied procedural risks after carotid intervention in a novel, international administrative data set of 18,997 patients admitted to 28 hospitals across 7 countries.

METHODS

Symptomatic and asymptomatic patients undergoing CEA (n = 16,220) and CAS (n = 2,777) between 2011 and 2015 were studied retrospectively. The primary outcome was in-hospital death within seven days. The secondary outcome was the proportion of patients whose length of hospital stay (LOS) exceeded 2 days. We also describe the rate of computerized tomography brain imaging within 2 days of CEA and CAS (proxy for stroke) as procedural strokes were not reliably recorded.

RESULTS

In symptomatic patients after CEA, mortality was 0.2% [5/2,118] (95% confidence interval: 0.1-0.5), and 57.0% [628/1,101] (54.1-60.0) had prolonged LOS. In asymptomatic patients after CEA, mortality was 0.1% [21/14,102] (0.1-0.2), and 28.5% [2,864/10,039] (27.7-29.4) had prolonged LOS. In symptomatic patients after CAS, mortality was 3.3% [10/307] (1.3-5.2), and 64.3% [144/224] (58.0-70.5) had prolonged LOS. In asymptomatic patients after CAS, mortality was 0.7% [18/2,470] (0.4-1.1), and 27.5% [601/2,187] (25.6-29.4) had prolonged LOS. After CEA, 8.1% [89/1,101] (6.5-9.7) symptomatic patients and 2.1% [207/10,039] (1.8-2.3) asymptomatic patients underwent brain imaging. After CAS, 7.1% [16/224] (4.0-10.7) symptomatic patients and 3.2% [71/2,187] (2.5-4.0) asymptomatic patients underwent brain imaging.

CONCLUSIONS

Death and LOS after CEA and CAS were higher in symptomatic than asymptomatic patients. Symptomatic patients undergoing CAS had particularly increased risk of death. This may be partly explained by case selection, with more comorbid patients preferentially undergoing CAS. While RCTs effectively compare long-term efficacy of CEA versus CAS, administrative datasets can provide reliable estimates of contemporary procedural risks.

Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative

OBJECTIVE

This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care.

DESIGN

A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set.

SETTING

23 large hospitals in Australia, England and the USA.

METHODS

Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals.

RESULTS

69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay.

CONCLUSIONS

Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.

Impact of laparoscopic versus open surgery on hospital costs for colon cancer: a population-based retrospective cohort study

OBJECTIVE

Laparoscopy is increasingly being used as an alternative to open surgery in the treatment of patients with colon cancer. The study objective is to estimate the difference in hospital costs between laparoscopic and open colon cancer surgery.

DESIGN

Population-based retrospective cohort study.

SETTINGS

All acute hospitals of the National Health System in England.

POPULATION

A total of 55 358 patients aged 30 and over with a primary diagnosis of colon cancer admitted for planned (elective) open or laparoscopic major resection between April 2006 and March 2013.

PRIMARY OUTCOMES

Inpatient hospital costs during index admission and after 30 and 90 days following the index admission.

RESULTS

Propensity score matching was used to create comparable exposed and control groups. The hospital cost of an index admission was estimated to be £1933 (95% CI 1834 to 2027; p<0.01) lower among patients who underwent laparoscopic resection. After including the first unplanned readmission following index admission, laparoscopy was £2107 (95% CI 2000 to 2215; p<0.01) less expensive at 30 days and £2202 (95% CI 2092 to 2316; p<0.01) less expensive at 90 days. The difference in cost was explained by shorter hospital stay and lower readmission rates in patients undergoing minimal access surgery. The use of laparoscopic colon cancer surgery increased 4-fold between 2006 and 2012 resulting in a total cost saving in excess of £29.3 million for the National Health Service (NHS).

CONCLUSIONS

Laparoscopy is associated with lower hospital costs than open surgery in elective patients with colon cancer suitable for both interventions.

Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality.

METHODS

MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data.

RESULTS

Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy.

CONCLUSION

Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

Safety and feasibility of laparoscopic colo-rectal surgery for cancer at a tertiary center in a developing country: Egypt as an example

BACKGROUND

Laparoscopic colectomy has been shown to have significant short- and long-term benefits compared to open approach. The incorporation of laparoscopy in developing countries is challenging, due to the high costs of equipment and lack of expertise. The aim of this study was to evaluate the safety and feasibility of laparoscopic colorectal surgery for cancer that could be performed in developing countries under different circumstances in developed countries.

METHODS

Thirty-seven patients (23 males and 14 females) with colorectal cancer with a median age of 46 years (39-72) have been enrolled for laparoscopic colo-rectal surgery in a tertiary center in Egypt (South Egypt Cancer Institute) with the trend of reuse of some disposable laparoscopic instruments.

RESULTS

The median operative time was 130 min (95-195 min). The median estimated blood loss was 70 ml (30-90 ml). No major intra-operative complications have been encountered. Two cases (5.5%) have been converted because of local advancement (one case) and bleeding with unavailability of vessel sealing device at that time (one case). The median time for passing flatus after surgery was 36 h (12-72 h). The median hospital stay was 4.8 days (4-7 days). The peri-operative period passed without events. Pathologic outcome revealed that the median number of retrieved lymph nodes was 14 (range 9-23 lymph node) and all cases had free surgical margin.

CONCLUSION

Laparoscopic colorectal surgery for cancer in developing countries could be safe and feasible. Safe reuse of disposable expensive parts of some laparoscopic instruments could help in propagation of this technique in developing countries.