Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review

Should we encourage the use of robotic technologies in complicated diverticulitis? Results of systematic review and meta-analysis

Introduction: Complicated diverticulitis is a common abdominal emergency that often requires a surgical intervention. The systematic review and meta-analysis below compare the benefits and harms of robotic vs. laparoscopic surgery in patients with complicated colonic diverticular disease. Methods: The following databases were searched before 1 March 2023: Cochrane Library, PubMed, Embase, CINAHL, and ClinicalTrials.gov. The internal validity of the selected non-randomized studies was assessed using the ROBINS-I tool. The meta-analysis and trial sequential analysis were performed using RevMan 5.4 (Cochrane Collaboration, London, United Kingdom) and Copenhagen Trial Unit Trial Sequential Analysis (TSA) software (Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark), respectively. Results: We found no relevant randomized controlled trials in the searched databases. Therefore, we analyzed 5 non-randomized studies with satisfactory internal validity and similar designs comprising a total of 442 patients (184 (41.6%) robotic and 258 (58.4%) laparoscopic interventions). The analysis revealed that robotic surgery for complicated diverticulitis (CD) took longer than laparoscopy (MD = 42 min; 95% CI: [-16, 101]). No statistically significant differences were detected between the groups regarding intraoperative blood loss (MD = -9 mL; 95% CI: [-26, 8]) and the rate of conversion to open surgery (2.17% or 4/184 for robotic surgery vs. 6.59% or 17/258 for laparoscopy; RR = 0.63; 95% CI: [0.10, 4.00]). The type of surgery did not affect the length of in-hospital stay (MD = 0.18; 95% CI: [-0.60, 0.97]) or the rate of postoperative complications (14.1% or 26/184 for robotic surgery vs. 19.8% or 51/258 for laparoscopy; RR = 0.81; 95% CI: [0.52, 1.26]). No deaths were reported in either group. Discussion: The meta-analysis suggests that robotic surgery is an appropriate option for managing complicated diverticulitis. It is associated with a trend toward a lower rate of conversion to open surgery and fewer postoperative complications; however, this trend does not reach the level of statistical significance. Since no high quality RCTs were available, this meta-analysis isnot able to provide reliable conclusion, but only a remarkable lack of proper evidence supporting robotic technology. The need for further evidence-based trials is important.

Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis

BACKGROUND

Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA.

OBJECTIVE

The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary care IBD center.

PATIENTS

All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks.

RESULTS

The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05).

LIMITATIONS

This study was limited by its retrospective design and evolving electronic medical charts system.

CONCLUSIONS

The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693.

LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA

ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease

To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.

Training for Minimally Invasive Surgery for IBD: A Current Need

Surgery for inflammatory bowel diseases (IBD) management has passed through an important evolution over the last decades, with innovative strategies and new technologies, especially in minimally invasive surgery (MIS) approaches. MIS procedures for IBD include multiport laparoscopy, single-port surgery, robotics, and the use of transanal platforms. These approaches can be used in the surgical management of both Crohn's disease (CD) and ulcerative colitis (UC). There are significant peculiarities in the surgical field in CD and UC, and their perfect understanding are directly related to better outcomes in IBD patients, as a consequence of improvement in knowledge by IBD surgeons. Different strategies to train colorectal surgeons were developed worldwide, for better application of MIS, usually for malignant or non-IBD benign diseases. There is a significant lack of evidence in specific training strategies for MIS in the IBD field. In this review, the authors outline the importance of adequate surgical training in IBD MIS, by discussing the current evidence on different approaches and emphasizing the need for better training protocols included in multidisciplinary teams in IBD centers throughout the globe.

Robotic Surgery in Inflammatory Bowel Disease

BACKGROUND

Surgery is considered a cornerstone of inflammatory bowel disease (IBD) treatment. In the last years, robotic surgery has seen an increase in adoption rates for both benign and malignant diseases.

OBJECTIVE

This work aims to review the current applications of robotic surgery in IBD.

DISCUSSION AND CONCLUSION

Minimally-invasive techniques have been applied to the treatment of IBD for more than 20 years. Investments in surgical digital and robotic platforms are increasingly arising, with an estimate of getting doubled within the next 5 years. Robotic surgery represents the newest technology available to reduce the impact of surgery on patients affected by IBD, and may theoretically be even more effective than other minimally-invasive techniques given the lower rate of conversion to open surgery as compared to laparoscopy according to many large retrospective series. Data on robotic surgery applied to IBD are still scarce and initial experiences in high-volume centers from retrospective series suggested that robotic surgery may achieve similar results when compared to laparoscopy. A new wave of robotics incorporating artificial intelligence is awaited to empower the capability of IBD surgeon in terms of intraoperative decision-making beyond technical skill enhancement.

Robotic Total Mesorectal Excision for Rectal Cancer: Short-Term Oncological Outcomes of Initial 178 Cases

Emerging techniques in minimally invasive rectal resection include robotic total mesorectal excision (R-TME). The Da Vinci Surgical System offers precise dissection in narrow and deep confined spaces and is gaining increasing acceptance during recent times. The aim of this study is to analyse our initial experience of R-TME with Da Vinci Xi platform in terms of perioperative and oncological outcomes in the context of data from recently published randomised ROLARR trial amongst minimally invasive novice surgeons. Patients who underwent R-TME or tumour specific mesorectal excision for rectal cancer between May 2016 and November 2019 were identified from a prospectively maintained single institution colorectal database. Demographic, clinical-pathological and short-term oncological outcomes were analysed. Of the 178 patients, 117 (65.7%) and 31 (17.4%) patients had lower and mid third rectal cancer. Most of the tumours were locally advanced, cT3–T4: 138 (77.5%). One hundred/178 (56.2%) underwent sphincter preserving TME. Eighty-seven (48.8%) were grade II adenocarcinoma. Nonmucinous adenocarcinoma was the predominant histology, 138 (78.4%). One hundred one cases (56.7%) were pT3. The mean number of lymph node yield was 13 ± 5. Distal resection margin and circumferential resection margin were positive in 2 (1.12%), 12 cases (6.74%) respectively. Eleven cases (6.7%) had to be converted to open TME. Mean blood loss and duration of surgery was 170 ± 60 ml and 286 ± 45 min respectively. Five percent cases had an anastomotic leak. Grade IIIa–IIIb Clavien Dindo (CD) morbidity score was reported to be in 12 (6.75%) and 10 (5.61%) cases. Median length of hospitalisation was 7 days (range 4–14 days). Perioperative and pathologic outcomes following robotic rectal resection is associated with good short-term oncological outcomes and is safe, effective, and reproducible by a minimally invasive novice surgeon.

Industry Payments in Colon and Rectal Surgery: A Cross-Sectional Analysis of Open Payments Data

BACKGROUND

The Physician Payments Sunshine Act of 2010 mandated publication of all financial relationships between companies and physicians on the Centers for Medicare and Medicaid Services' Open Payments Data to elucidate potential conflicts of interest. This study seeks to illuminate the financial relationships that the pharmaceutical, medical device, biologics, and medical supply industries maintained with colon and rectal surgeons across the United States from 2014 to 2018.

MATERIALS AND METHODS

We extracted and analyzed all colon and rectal surgeon data from the Open Payments Data for 2014-2018 using Microsoft Excel 2018 and JMP PRO 13.2.0 (SAS Institute). We calculated descriptive statistics and displayed prominent trends in the data.

RESULTS

From 2014 to 2018, totals of $26,841,274 in general payments and $7,492,822 in research payments were made to 1935 and 150 colorectal surgeons, respectively. Intuitive Surgical, Inc paid the most money in general payments every year, ranging from 39.0% to 58.8% of the total payment amount. Intuitive Surgical, Inc's product, da Vinci Surgical System, had the greatest number of payments, totaling 21,191 general payments. The year with the highest amount paid for research was 2017, in which a total of $2,810,558 was paid to colorectal surgeons.

CONCLUSIONS

Companies across industries paid millions of dollars to colorectal surgeons from 2014 to 2018. However, further research is required to determine the causal effects of these surgeons' financial relationships with the industry on research, prescription, and technology adoption practices.

[Robotic Assisted Proctocolectomy with Ileal Pouch-Anal Anastomosis in a Case of Suspected Hereditary Polyposis]

BACKGROUND

Various forms of hereditary polyposis have been described in the literature. Classical familial adenomatous polyposis (FAP) is a rare, autosomal dominantly inherited disease which is caused by a germline mutation in the adenomatous polyposis coli gene (APC). Patients with this diagnosis successively develop multiple polyps of the colon. Left untreated, FAP almost inevitably leads to malignant transformation.

INDICATION

We present the case of a 37-year-old patient with histologically confirmed, stenotic adenocarcinoma of the descending colon and an initially suspected hereditary polyposis due to multiple polyps in the descending and sigmoid colon.

METHODS

The video describes the preoperative imaging as well as endoscopic findings and demonstrates the technique of a two-stage, robotically assisted proctocolectomy with ileal pouch-anal anastomosis (IPAA) and the creation of a temporary loop ileostomy.

CONCLUSIONS

With respect to the surgical treatment of classic FAP, restorative proctocolectomy (RPC) with ileal J-pouch construction can be regarded as an established standard procedure, despite controversy regarding various technical aspects. Minimally invasive strategies should be considered as an equivalent option compared to conventional techniques.

The Current Role of Robotics in Colorectal Surgery

PURPOSE OF REVIEW

Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an open approach. Reasons for this may include technical difficulties associated with operating in narrow spaces such as in the pelvis and inadequate experience. Robotic surgery provides potential solutions to some of these challenges. This review will summarize the state of the literature regarding robotic colorectal surgery.

RECENT FINDINGS

The most consistent benefit of robotic surgery is decreasing operative conversions, specifically in rectal cancer. In partial colectomies, there is evidence to support quicker return to bowel function. Oncologic outcomes compared to the laparoscopic approach are equivalent. Robotic surgery provides solutions to the challenges posed by laparoscopy, including wristed instruments, ease of intracorporeal suturing, and ergonomic advantages. Randomized trials to evaluate peri-operative outcomes will be important. If robotics is able to facilitate conversion of open colectomies to their minimally invasive equivalent, robotics may end up proving to be advantageous in the peri-operative and post-operative period. Continued studies are warranted.