Laparoscopic vs open colectomy for colon cancer: results from a large nationwide population-based analysis

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience

BACKGROUND

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections.

METHODS

In 2013, a laparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study.

RESULTS

A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17 cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94 patients (84%). Among the complications, wound infection was seen in seven patients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively.

CONCLUSION

This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

The Not-So-Distant Future or Just Hype? Utilizing Machine Learning to Predict 30-Day Post-Operative Complications in Laparoscopic Colectomy Patients

BACKGROUND

Complex machine learning (ML) models have revolutionized predictions in clinical care. However, for laparoscopic colectomy (LC), prediction of morbidity by ML has not been adequately analyzed nor compared against traditional logistic regression (LR) models.

METHODS

All LC patients, between 2017 and 2019, in the National Surgical Quality Improvement Program (NSQIP) were identified. A composite outcome of 17 variables defined any post-operative morbidity. Seven of the most common complications were additionally analyzed. Three ML models (Random Forests, XGBoost, and L1-L2-RFE) were compared with LR.

RESULTS

Random Forests, XGBoost, and L1-L2-RFE predicted 30-day post-operative morbidity with average area under the curve (AUC): .709, .712, and .712, respectively. LR predicted morbidity with AUC = .712. Septic shock was predicted with AUC ≤ .9, by ML and LR.

CONCLUSION

There was negligible difference in the predictive ability of ML and LR in post-LC morbidity prediction. Possibly, the computational power of ML cannot be realized in limited datasets.

Preoperative stents for the treatment of obstructing left-sided colon cancer: a national analysis

BACKGROUND

Given the risks associated with urgent colectomy for large bowel obstruction, preoperative colonic stenting has been utilized for decompression and optimization prior to surgery. This study examined national trends in the use of colonic stenting as a bridge to resection for malignant large bowel obstruction and evaluated outcomes relative to immediate colectomy.

METHODS

Adults undergoing colonic stenting or colectomy for malignant, left/sigmoid large bowel obstruction were identified in the 2010-2016 Nationwide Readmissions Database. Patients were classified as immediate resection (IR) or delayed resection (DR) if undergoing colonic stenting prior to colectomy. Generalized linear models were used to evaluate the impact of resection strategy on ostomy creation, in-hospital mortality, and complications.

RESULTS

Among 9,706 patients, 9.7% underwent colonic stenting, which increased from 7.7 to 16.4% from 2010 to 2016 (p < 0.001). Compared to IR, the DR group was younger (63.9 vs 65.9 years, p = 0.04), had fewer comorbidities (Elixhauser Index 3.5 vs 3.9, p = 0.001), and was more commonly managed at high-volume centers (89.4% vs 68.1%, p < 0.001). Laparoscopic resections were more frequent among the DR group (33.1% vs 13.0%, p < 0.001), while ostomy rates were significantly lower (21.5% vs 53.0%, p < 0.001). After risk adjustment, colonic stenting was associated with reduced odds of ostomy creation (0.34, 95% confidence interval 0.24-0.46), but similar odds of mortality and complications.

CONCLUSION

Colonic stenting is increasingly utilized for malignant, left-sided bowel obstructions, and associated with lower ostomy rates but comparable clinical outcomes. These findings suggest the relative safety of colonic stenting for malignant large bowel obstruction when clinically appropriate.

Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data

Background

Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data.

Methods

Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery.

Results

A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations.

Conclusions

Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.

Ureteral injuries in colorectal surgery and the impact of laparoscopic and robotic-assisted approaches

BACKGROUND

Ureteral injury is a feared complication in colorectal surgery that has been increasing over the past decade. Some have attributed this to an increased adoption of minimally invasive surgery (MIS), but the literature is hardly conclusive. In this study we aim to further assess the overall trend of ureteral injuries in colorectal surgery, and investigate propensity adjusted contributions from open and MIS to include robotic-assisted surgery.

METHODS

This is a retrospective analysis of colorectal surgeries from 2006 to 2016 using the Nationwide Inpatient Sample (NIS) database. Multivariable logistic regression was performed to identify predisposing and protective factors. Demographics, hospital factors, and case-mix differences for open and MIS were accounted for via propensity analysis. The NIS coding structure changed in 2015, which could introduce a potential source of incongruity in complication rates over time. As a result, all statistical analyses included only the first nine years of data, or were conducted before and after the change for comparison.

RESULTS

Of 514,162 colorectal surgeries identified there were 1598 ureteral injuries (0.31%). Ureteral injuries were found to be increasing through 2015 (2.3/1000 vs 3.3/1000; p < 0.001) and through the coding transition to 2016 (4.8/1000; p < 0.001). This trend was entirely accounted for by injuries made during open surgery, with decreasing injury rates for MIS over time. Adjusted odds ratio (OR) for ureteral injury with all MIS vs. open cases was 0.81 (95% CI 0.70-0.93, p = 0.003) and for robotic-assisted surgery alone versus open cases was 0.50 (95% CI 0.33-0.77, p = 0.001).

CONCLUSIONS

The incidence rate of ureteral injuries during open colorectal surgery is increasing over time, but have been stable or decreasing for MIS cases. These findings hold even after using propensity score analysis. More research is needed to further delineate the impact of MIS and robotic-assisted surgery on ureteral injuries.

Laparoscopic surgery for colon cancer

Background

To evaluate a new procedure in daily clinical practice, it might not be sufficient to rely exclusively on the findings of randomized clinical trials (RCTs). This is the first systematic review providing a synthesis of the most important RCTs and relevant retrospective cohort studies on short- and long-term outcomes of laparoscopic surgery in colon cancer patients.

Materials and methods

In a literature search, more than 1800 relevant publications on the topic were identified. Relevant RCTs and representative high-quality retrospective studies were selected based on the widely accepted Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Finally, 9 RCTs and 14 retrospective cohort studies were included.

Results

Laparoscopic surgery for colon cancer is associated with a slightly longer duration of surgery, but a variety of studies show an association with a lower rate of postoperative complications and a shorter duration of hospital stay. Particularly in older patients with more frequent comorbidities, laparoscopy seems to contribute to decreasing postoperative mortality. Concerning long-term oncologic outcomes, the laparoscopic and open techniques were shown to be at least equivalent.

Conclusion

The findings of the existing relevant RCTs on laparoscopic surgery for colon cancer are mostly confirmed by representative retrospective cohort studies based on real-world data; therefore, its further implementation into clinical practice can be recommended.

Use, Cost, Complications, and Mortality of Robotic versus Nonrobotic General Surgery Procedures Based on a Nationwide Database

Since its introduction in 1997, robotic surgery has overcome many limitations, including setup costs and surgeon training. The use of robotics in general surgery remains unknown. This study evaluates robotic-assisted procedures in general surgery by comparing characteristics with its nonrobotic (laparoscopic and open) counterparts. Weighted Healthcare Cost and Utilization Project Nationwide Inpatient Sample data (2008, 2009) were used to identify the top 12 procedures for robotic general surgery. Robotic cases were identified by Current Procedural Terminology codes 17.41 and 17.42. Procedures were grouped: esophagogastric, colorectal, adrenalectomy, lysis of adhesion, and cholecystectomy. Analyses were descriptive, t tests, χ2s, and logistic regression. Charges and length of stay were adjusted for gender, age, race, payer, hospital bed size, hospital location, hospital region, median household income, Charlson score, and procedure type. There were 1,389,235 (97.4%) nonrobotic and 37,270 (2.6%) robotic cases. Robotic cases increased from 0.8 per cent (2008) to 4.3 per cent (2009, P < 0.001). In all subgroups, robotic surgery had significantly shorter lengths of stay (4.9 days) than open surgery (6.1 days) and lower charges (median $30,540) than laparoscopic ($34,537) and open ($46,704) surgery. Fewer complications were seen in robotic-assisted colorectal, adrenalectomy and lysis of adhesion; however, robotic cholecystectomy and esophagogastric procedures had higher complications than nonrobotic surgery ( P < 0.05). Overall robotic surgery had a lower mortality rate (0.097%) than nonrobotic surgeries per 10,000 procedures (laparoscopic 0.48%, open 0.92%; P < 0.001). The cost of robotic surgery is generally considered a prohibitive factor. In the present study, when overall cost was considered, including length of stay, robotic surgery appeared to be cost-effective and as safe as nonrobotic surgery except in cholecystectomy and esophagogastric procedures. Further study is needed to fully understand the long-term implications of this new technology.

Changing Demographics in Laparoscopic Cholecystectomy Performed in the United States: Hospitalizations from 1998 to 2010

In the clinical experience at a community hospital, younger patients appear to be receiving more laparoscopic cholecystectomy (LC). The purpose of this study was to determine if LC is increasing in the younger patient population and if obesity is associated with the increase in LC. Patients undergoing LC were identified from the Healthcare Cost Utilization Project Nationwide Inpatient Sample database. There were 4,449,643 LCs from 1998 to 2010. Patients 15 to 24 years of age had the largest increase in LC (3.2%) and obesity (10.8%) from 1998 to 2010. In the 15- to 24-year age group, the following variables were associated with obesity: female, white, private payer, nonteaching hospital, urban location, southern region, large hospital bed size, and 31 Charlson group, all P < 0.05. Additionally in the 15- to 24-year age group, median length of stay (nonobese 2 days vs obese 3 days) and median cost (nonobese $19,170 vs obese $22,802) were both increased ( P < 0.001). The percentage of younger people having LC is increasing with highest increases in the obese population. The obese youth also have longer length of stay with an increase in hospital cost. These results suggest a rising disease burden associated with obesity among people ages 15 to 24 years. Gallstone disease burden will likely increase with the increase in prevalence of obesity and would add to healthcare economic burden.

Effect of Transfer Status on Outcomes of Emergency General Surgery Patients

INTRODUCTION

Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.

METHODS

We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.

RESULTS

We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.

CONCLUSIONS

EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.

Comparison of outcome and cost between the open, laparoscopic, and robotic surgical treatments for colon cancer: a propensity score-matched analysis using nationwide hospital record database

BACKGROUND

There are limited studies that compare the cost and outcome of robotic-assisted surgery to open and laparoscopic surgery for colon cancer treatment. We aimed to compare the three surgical modalities for colon cancer treatment.

METHODS

We performed a cohort study using the population-based Nationwide Inpatient Sample database. Patients with a primary diagnosis of colon cancer who underwent robotic, laparoscopic, or open surgeries between 2008 and 2014 were eligible for enrollment. We compared in-hospital mortality, complications, length of hospital stay, and cost for patients undergoing one of these three procedures using a multivariate adjusted logistic regression analysis and propensity score matching.

RESULTS

Of the 531,536 patients undergoing surgical treatment for colon cancer during the study period, 348,645 (65.6%) patients underwent open surgeries, 174,748 (32.9%) underwent laparoscopic surgeries, and 8143 (1.5%) underwent robotic surgeries. In-hospital mortality, length of hospital stay, wound complications, general medical complications, general surgical complications, and costs of the three surgical treatment modalities. Compared to those undergoing laparoscopic surgery, patients undergoing open surgery had a higher mortality rate (OR 2.98, 95% CI 2.61-3.40), more general medical complications (OR 1.77, 95% CI 1.67-1.87), a longer length of hospital stay (6.60 vs. 4.36 days), and higher total cost ($18,541 vs. $14,487) in the propensity score matched cohort. Mortality rate and general medical complications were equivalent in the laparoscopic and robotic surgery groups, but the median cost was lower in the laparoscopic group ($14641 vs. $16,628 USD).

CONCLUSIONS

Laparoscopic colon cancer surgery was associated with a favourable short-term outcome and lower cost compared with open surgery. Robot-assisted surgery had comparable outcomes but higher cost as compared to laparoscopic surgery.

Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study

AIM

Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery.

RESULTS

Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P < 0.001).

CONCLUSIONS

The 5-mFI is a valid and easy to use predictor of 30-day postoperative outcomes after colorectal surgery. This tool may guide the surgeon to proactively recognize frail patients to instigate interventions to optimize them preoperatively.

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

Minimally invasive surgery for colorectal cancer remains underutilized in Germany despite its nationwide application over the last decade

Minimally invasive surgery (MIS) has superior short-term outcomes than open surgery (OS) for colorectal cancer (CRC). However, a nationwide dataset has not been analysed to confirm these findings. We evaluated the distribution and outcomes of MIS for CRC from 2005 to 2015; all in-patients with CRC surgery procedure codes were identified from hospital data, which are entered into the nationwide diagnosis-related group database and forwarded anonymised to the Federal Bureau of Statistics. We determined absolute MIS, morbidity, and mortality rates for specific sub-categories, including procedure type. We identified 345,913 in-patient files. The MIS rate increased from 6.4% (n = 2366; 2005) to 28.5% (n = 8363; 2015), with the highest rates for sigmoid colon (38%) and rectal (39%) resections. The overall conversion rate was 14.4%, without noticeable improvement over time. International Classification of Disease codes related to postoperative complications were documented more frequently after OS than after MIS. OS was associated with a higher mortality rate (4.7%) than MIS (1.8%) (P < 0.001), even after stratifying patients according to the resection site. Use of MIS remains low in Germany compared with that in other European countries. Underutilization of MIS has to be addressed in the future by promoting structured training programs and standardization of laparoscopic surgery.

Long-term oncologic outcomes after laparoscopic vs. open colon cancer resection: a high-quality population-based analysis in a Southern German district

Background

Over 20 years after the introduction of laparoscopic surgery for colon cancer, many surgeons still prefer the open approach. Whereas randomized controlled trials (RCTs) have proven the oncologic safety of laparoscopy, long-term data depicting daily clinical routine are scarce.

Methods

This population-based cohort study compares 5-year overall, relative, and recurrence-free survival rates after laparoscopic and open colon carcinoma surgery. Data derive from an independent German cancer registry encompassing all tumor patients within a political district of 1.1 million inhabitants. The final analysis included 2669 patients with major elective resection of primary non-metastatic colonic adenocarcinoma between January 1, 2004 and December 31, 2013. Survival rates were compared using Kaplan–Meier analyses, relative survival models, and multivariate Cox regression. Sensitivity analysis quantified selection bias.

Results

The proportion of laparoscopic procedures increased from 9.7 to 25.8% in 2011 and dropped again to 15.8% at the end of observation period. Laparoscopy patients were younger, had a lower tumor stage, and were more likely to receive postoperative chemotherapy. Overall, relative, and recurrence-free survival was significantly superior or equivalent in Kaplan–Meier analysis (5-year overall survival rate open vs. laparoscopic: 69.0 vs. 80.2%, p < 0.001). The superiority of laparoscopy mostly remained stable after adjusting for confounders, although significance was only reached in T1-3 patients without lymph node metastases (overall survival: hazard ratio (HR) 0.654; 95% confidence interval (CI) 0.446–0.958; p = 0.029).

Conclusion

Laparoscopy is a safe and promising alternative to the open approach in daily clinic practice. These favorable outcomes require future confirmation by high-quality studies outside the setting of RTCs.

Changes of serum and peritoneal inflammatory mediators in laparoscopic radical resection for right colon carcinoma

Objective:

The objective of this study is to investigate the effects of laparoscopic and open operation on serum and peritoneal inflammatory mediators in patients with right colon carcinoma.

Patients and Methods:

A total of 100 patients were randomly divided into laparoscopic group (n = 50) and open group (n = 50). The age, sex, operation time, operation blood loss, post-operative Dukes stage, time to first passage of flatus and post-operative hospital stay were recorded. The levels of hypersensitive C reactive protein (hsCRP) and tumour necrosis factor-α (TNF-α) in serum and abdominal exudate were measured by ELISA at the time of pre-operative 2 h and post-operative 6 h and 24 h.

Results:

There was no significant difference in age, sex, Dukes stage and pre-operative inflammatory mediators between the two groups (P > 0.05). The operation time, intraoperative blood loss, time to first passage of flatus and post-operative hospital stay were significantly better in laparoscopic group than those in open operation group. At 6 h and 24 h after operation, the levels of hsCRP and TNF-α in serum and abdominal exudate in laparoscopic group were significantly lower than those in open operation group.

Conclusions:

Laparoscopic surgery for the treatment of right colon carcinoma has the advantages of fewer traumas, less systemic and local inflammatory response, rapider post-operative recovery and shorter hospital stay. It is worthy of clinical application.

Hand-assisted laparoscopic surgery versus laparoscopic right colectomy: a meta-analysis

Objective

The objective of this study is to systematically assess the clinical efficacy of hand-assisted laparoscopic surgery (HALS) and laparoscopic right colectomy (LRC).

Methods

The randomized controlled trials (RCTs) and non-RCTs were collected by searching electronic databases (Pubmed, Embase, and the Cochrane Library). The outcomes included intraoperative outcomes, postoperative outcomes, postoperative morbidity, and oncologic outcomes. Meta-analysis was performed using of RevMan 5.3 software.

Results

A total of five studies involving 438 patients were finally included, with 202 cases in HALS group and 236 cases in LRC group. Results of meta-analysis showed that there was no statistical difference between HALS and LRC in terms of conversion rate, length of hospital stay, reoperation rate, postoperative morbidity, and oncologic outcomes. The operative time was 6.5 min shorter in HALS group; however, it was not a clinically significant difference. Although the incision length was longer in HALS, it did not influence the postoperative recovery.

Conclusions

HALS can be considered an alternative to LRC which combines the advantages of open as well as laparoscopic surgery.

A meta-analysis of short-term outcome of laparoscopic surgery versus conventional open surgery on colorectal carcinoma

OBJECTIVE

The aim of this article is to study the superiority and safety of laparoscopic surgery for colorectal carcinoma.

SUMMARY BACKGROUND DATA

Laparoscopy in rectal cancer is still not recommended as the treatment of choice by National Comprehensive Cancer Network guidelines. Laparoscopic rectal surgery is more complex and technically demanding, especially for mid and low rectal cancer.

METHODS

A computer-based online research of retrospective or prospective studies addressing laparoscopic surgery versus conventional open surgery for colorectal carcinoma published in the last 11 years was performed in electronic database (Wangfang Database, China National Knowledge Infrastructure, Chinese Medical Current Contents, Pubmed, Medline, Ovid, Elsevier, ISI Web of Knowledge, Cohrane Database of Systematic Reviews). Selective trials were analyzed by the Review Manager 5.2 software.

RESULTS

A total of 9 clinical trials, involving a total of 4747 patients, were identified. A meta-analysis showed that operating time was not significantly different between the 2 groups [WMD = 0.46, 95% confidence interval (95% CI): -55.68 to 56.60, P = .99], intraoperative blood loss in laparoscopic surgery group was less than conventional open surgery group (WMD = -64.66, 95% CI: -87.31 to 42.01, P < .01); No significant difference in the number of lymph node retrieved from postoperative pathologic specimens was found between the 2 groups (WMD = -0.75, 95% CI: -1.72 to 0.23, P = .14); Postoperative time to flatus in laparoscopic surgery group was earlier than that in open surgery significantly (WMD = -1.22, 95% CI: -1.53 to -0.91, P < .01). The cases of postoperative complications were significantly different between the 2 groups, which showed that the cases of laparoscopic surgery group were less than those of open surgery group [odds ratio (OR) = 0.62, 95% CI: 0.52∼0.72, P < .01]; Moreover, hospital stay of laparoscopic surgery group was shorter than that of open surgery that showed significant difference (WMD = -2.38, 95% CI:-3.30 to -1.46, P < .01).

CONCLUSION

Short-term outcomes of laparoscopic surgery are superior than conventional open surgery that include more safety and feasibility, and is expected to be a standardization operation method for colorectal carcinoma.

Patient, Hospital, and Geographic Disparities in Laparoscopic Surgery Use Among Surveillance, Epidemiology, and End Results-Medicare Patients With Colon Cancer

BACKGROUND

Surgical resection is the primary treatment for colon cancer, but use of laparoscopic approaches varies widely despite demonstrated short- and long-term benefits.

OBJECTIVE

The purpose of this study was to identify characteristics associated with laparoscopic colon cancer resection and to quantify variation based on patient, hospital, and geographic characteristics.

DESIGN

Bayesian cross-classified, multilevel logistic models calculated adjusted ORs and CIs for patient, surgeon, hospital, and geographic characteristics and unexplained variability (predicted vs. observed values) using adjusted median odds ratios for hospitals and counties.

SETTINGS

The Surveillance, Epidemiology, and End Results-Medicare claims database (2008-2011) supplemented with county-level American Community Survey (2008-2012) demographic data was used.

PATIENTS

A total of 10,618 patients ≥66 years old who underwent colon cancer resection were included.

MAIN OUTCOME MEASURES

Nonurgent/nonemergent resections for colon cancer patients ≥66 years old were classified as laparoscopic or open procedures.

RESULTS

Patients resided in 579 counties and used 950 hospitals; 47% of patients underwent laparoscopic surgery. Medicare/Medicaid dual enrollment, age ≥85 years, and higher tumor stage and grade were negatively associated with laparoscopic surgery receipt; proximal tumors and increasing hospital size and surgeon caseload were positively associated. Significant unexplained variability at the hospital (adjusted median OR = 3.31; p < 0.001) and county levels (adjusted median OR = 1.28; p < 0.05) remained after adjustment.

LIMITATIONS

This was an observational study lacking generalizability to younger patients without Medicare or those with Health Maintenance Organization coverage and data set did not reflect national hospital studies or hospital volume. In addition, we were unable to account for specific types of comorbidities, such as obesity, and had broad categories for surgeon caseload.

CONCLUSIONS

Determining sources of hospital-level variation among poor insured patients may help increase laparoscopic resection to maximize health outcomes and reduce cost. See Video Abstract at http://links.lww.com/DCR/A363.

Toward standardization of laparoscopic resection for colorectal cancer in developing countries: A step by step module

BACKGROUND

Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption.

OBJECTIVE

To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles.

PATIENTS AND METHODS

This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed.

RESULTS

The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient.

CONCLUSION

Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting.

Rethinking Priorities: Cost of Complications After Elective Colectomy

OBJECTIVE

To compare incremental costs associated with complications of elective colectomy using nationally representative data among patients undergoing laparoscopic/open resections for the 4 most frequent diagnoses.

SUMMARY BACKGROUND DATA

Rising healthcare costs have led to increasing focus on the need to achieve a better understanding of the association between costs and quality. Among elective colectomies, a focus of surgical quality-improvement initiatives, interpretable evidence to support existing approaches is lacking.

METHODS

The 2009 to 2011 Nationwide Inpatient Sample (NIS) data were queried for adult (≥18 years) patients undergoing elective colectomy. Patients with primary diagnoses for colon cancer, diverticular disease, benign colonic neoplasm, and ulcerative colitis/regional enteritis were included. Based on system-based complications considered relevant to long-term treatment of elective colectomy, stratified differences in risk-adjusted incremental hospital costs and complications probabilities were compared.

RESULTS

A total of 68,462 patients were included, weighted to represent 337,887 patients nationwide. A total of 16.4% experienced complications. Annual risk-adjusted incremental costs amounted to >$150 million. Magnitudes of complication prevalences/costs varied by primary diagnosis, operative technique, and complication group. Infectious complications contributed the most ($55 million), followed by gastrointestinal ($53 million), pulmonary ($22 million), and cardiovascular ($11 million) complications. Total annual costs for elective colectomies amounted to >$1.7 billion: 11.3% was due to complications [1.9% due to current Centers for Medicare and Medicaid Services (CMS) complications].

CONCLUSIONS

The results highlight a need to consider the varied/broad impact of complications, offering a stratified paradigm for priority setting in surgery. As we move forward in the development of novel/adaptation of existing interventions, it will be essential to weigh the cost of complications in an evidence-based way.

Trends and Outcomes of Surgical Treatment for Colorectal Cancer between 2004 and 2012- an Analysis using National Inpatient Database

Limited data are available for the epidemiology and outcome of colorectal cancer in relation to the three main surgical treatment modalities (open, laparoscopic and robotic). Using the US National Inpatient Sample database from 2004 to 2012, we identified 1,265,684 hospitalized colorectal cancer patients. Over the 9 year period, there was a 13.5% decrease in the number of hospital admissions and a 43.5% decrease in in-hospital mortality. Comparing the trend of surgical modalities, there was a 35.4% decrease in open surgeries, a 3.5 fold increase in laparoscopic surgeries, and a 41.3 fold increase in robotic surgeries. Nonetheless, in 2012, open surgery still remained the preferred surgical treatment modality (65.4%), followed by laparoscopic (31.2%) and robotic surgeries (3.4%). Laparoscopic and robotic surgeries were associated with lower in-hospital mortality, fewer complications, and shorter length of stays, which might be explained by the elective nature of surgery and earlier tumor grades. After excluding patients with advanced tumor grades, laparoscopic surgery was still associated with better outcomes and lower costs than open surgery. On the contrary, robotic surgery was associated with the highest costs, without substantial outcome benefits over laparoscopic surgery. More studies are required to clarify the cost-effectiveness of robotic surgery.

Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study

BACKGROUND

Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce.

METHODS

This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed.

RESULTS

2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%).

CONCLUSIONS

In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.

Location is everything: The role of splenic flexure mobilization during colon resection for diverticulitis

INTRODUCTION

Routine splenic flexure mobilization (SFM) has been previously recommended to ensure an adequate length for a tension free anastomosis during resection for diverticulitis. We sought to evaluate the role of selective SFM for diverticulitis, and its impact on outcomes.

MATERIALS AND METHODS

Retrospective review of elective colectomies at a tertiary care center (2007-2015) for left-sided diverticulitis were identified from the National Surgical Quality Improvement Program. Demographics and perioperative characteristics were compared; and 30-day risk-adjusted outcomes were assessed.

RESULTS

We identified 208 sigmoid/left colectomy cases. A laparoscopic approach predominated (71%), and SFM was performed in 54% of cases (n = 113). Demographics and comorbidities were similar. Median operative time was greater in the SFM group [226; interquartile range (IQR): (190-267) minutes] compared to no mobilization [180; IQR: (153-209) minutes] (p < 0.01). After risk adjustment, SFM was associated with a trend towards an increased rate of a minor morbidity (OR: 2.8; p = 0.05).

CONCLUSION

Splenic flexure mobilization was performed selectively in half of colectomies evaluated. This technique was associated with a trend towards an increased rate of minor complications, with no difference in major adverse events, including organ space infections. These findings suggest that for patient with diverticulitis, SFM should be performed in an individualized fashion.

Short-term outcomes of laparoscopic versus open total colectomy with ileorectal anastomosis: a case-matched analysis from a nationwide database

BACKGROUND

In the current study, we aimed to compare peri- and postoperative 30-day outcomes of patients undergoing laparoscopic versus open total colectomy with ileorectal anastomosis in a case-matched design using data procedure-targeted database.

METHODS

Patients who underwent elective total colectomy with ileorectal anastomosis in 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into two groups according to the type of surgical approach (laparoscopic and open). Laparoscopic and open groups were matched (1:1) based on age, gender, diagnosis, body mass index, and American Society of Anesthesiologists classification. Comorbidities, perioperative, and short-term (30-day) postoperative outcomes were compared between the matched groups.

RESULTS

We identified 1442 patients-549 in the laparoscopic group and 893 patients in the open group. After case matching, there were 326 patients in each group. There were 48 (14.7%) patients who had conversion in the laparoscopic group. The open group had a higher proportion of patients with ascites [0 (0%) vs. 7 (2.1%) p = 0.015], preoperative weight loss [26 (8.0%) vs. 45 (13.8%) p = 0.018], and contaminated wound classifications [Clean/Contaminated 261 (80%) vs. 240 (74%), Contaminated 55 (16.9%) vs. 54 (16.6%), and Dirty/Infected 8 (2.5%) vs. 28 (8.6%), (p = 0.003)]. The laparoscopic group had a significantly longer operative time (242 ± 98 vs. 202 ± 116 min, p < 0.001), shorter hospital stay (9.4 ± 8.5 vs. 13.3 ± 10.7 days, p < 0.001), and lower ileus rate (23.9 vs. 31.0%, p = 0.045) than the open group. After adjusting for covariates, the differences in terms of operative time and hospital stay remained significant [odds ratio (OR): 0.79, confidence interval (CI) 0.74-0.85 and OR 1.36, CI 1.21-1.52, p < 0.001, respectively].

CONCLUSIONS

Laparoscopic approach for total colectomy with ileorectal anastomosis is associated with a shorter hospital stay but longer operative time compared with an open approach.

A National Database Analysis Comparing the Nationwide Inpatient Sample and American College of Surgeons National Surgical Quality Improvement Program in Laparoscopic vs Open Colectomies: Inherent Variance May Impact Outcomes

BACKGROUND

Clinical and administrative databases each have fundamental distinctions and inherent limitations that may impact results.

OBJECTIVE

This study aimed to compare the American College of Surgeons National Surgical Quality Improvement Program and the Nationwide Inpatient Sample, focusing on the similarities, differences, and limitations of both data sets.

DESIGN

All elective open and laparoscopic segmental colectomies from American College of Surgeons National Surgical Quality Improvement Program (2006-2013) and Nationwide Inpatient Sample (2006-2012) were reviewed. International Classification of Diseases, Ninth Revision, Clinical Modification coding identified Nationwide Inpatient Sample cases, and Current Procedural Terminology coding for American College of Surgeons National Surgical Quality Improvement Program. Common demographics and comorbidities were identified, and in-hospital outcomes were evaluated.

SETTINGS

A national sample was extracted from population databases.

PATIENTS

Data were derived from the Nationwide Inpatient Sample database: 188,326 cases (laparoscopic = 67,245; open = 121,081); and American College of Surgeons National Surgical Quality Improvement Program: 110,666 cases (laparoscopic = 54,191; open = 56,475).

MAIN OUTCOME MEASURES

Colectomy data were used as an avenue to compare differences in patient characteristics and outcomes between these 2 data sets.

RESULTS

Laparoscopic colectomy demonstrated superior outcomes compared with open; therefore, results focused on comparing a minimally invasive approach among the data sets. Because of sample size, many variables were statistically different without clinical relevance. Coding discrepancies were demonstrated in the rate of conversion from laparoscopic to open identified in the National Surgical Quality Improvement Program (3%) and Nationwide Inpatient Sample (15%) data sets. The prevalence of nonmorbid obesity and anemia from National Surgical Quality Improvement Program was more than twice that of Nationwide Inpatient Sample. Sepsis was statistically greater in National Surgical Quality Improvement Program, with urinary tract infections and acute kidney injury having a greater frequency in the Nationwide Inpatient Sample cohort. Surgical site infections were higher in National Surgical Quality Improvement Program (30-day) vs Nationwide Inpatient Sample (8.4% vs 2.6%; p < 0.01), albeit less when restricted to infections that occurred before discharge (3.3% vs 2.6%; p < 0.01).

LIMITATIONS

This is a retrospective study using population-based data.

CONCLUSION

This analysis of 2 large national databases regarding colectomy outcomes highlights the incidence of previously unrecognized data variability. These discrepancies can impact study results and subsequent conclusions/recommendations. These findings underscore the importance of carefully choosing and understanding the different population-based data sets before designing and when interpreting outcomes research.

Real-world cost-effectiveness of laparoscopy versus open colectomy for colon cancer: a nationwide population-based study

BACKGROUND

Laparoscopic colectomy is increasingly being adopted for the treatment of colon cancer; however, the long-term effectiveness of this approach in a real-world clinical setting has yet to be verified. This study aims to compare the effectiveness and costs associated with laparoscopic and open colectomy from the perspective of the National Health Insurance (NHI) system in Taiwan.

METHODS

A nationwide population-based colon cancer cohort was observed by linking the Taiwan Cancer Registry, claims data from NHI system, and the National Death Registry. Adult patients with Stage I to Stage III colon cancer who underwent primary cancer resection using either laparoscopy or open colectomy between 2009 and 2011 were included. A propensity score-matched cohort (1745 pairs) was applied to examine three clinical endpoints: overall survival, recurrence-free survival, and disease-free survival within 2 years after the operation. To comply with the perspective as well as the analytic horizon of the study, we limited the research to NHI claims from the study population for the corresponding time period. The health outcomes and net monetary benefits were verified by multivariate mixed-effect models.

RESULTS

This analysis revealed that laparoscopy resulted in longer overall survival (adjusted difference 16.8 days, 95 % CI 7.3-26.2), recurrence-free survival (16.8 days, 5.0-28.6) and disease-free survival (26.4 days, 7.4-45.4), compared to open colectomy at 2 years post-op. Laparoscopy also led to a significantly shorter length of stay (3.2 days, 2.4-3.9) and lower index hospitalization costs (US$ 455, 181-729) than open colectomy; however, no differences in costs were observed over the long term. Overall, laparoscopy was more cost-effective than open colectomy under various willingness-to-pay thresholds in the setting of the Taiwan NHI.

CONCLUSIONS

The continued adoption of laparoscopy in primary curable colon cancer resection is expected to reduce health care costs over the short term while providing considerable health benefits over the long term.

Comparison of Open, Laparoscopic, and Robotic Colectomies Using a Large National Database: Outcomes and Trends Related to Surgery Center Volume

BACKGROUND

Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown.

OBJECTIVE

The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time.

DESIGN

This was a retrospective study.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status.

MAIN OUTCOME MEASURES

In-hospital mortality and postoperative complications of surgery were measured.

RESULTS

A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic).

LIMITATIONS

This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting.

CONCLUSIONS

Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.

Short-term outcomes of minimally invasive versus open colectomy for colon cancer

BACKGROUND

Laparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer.

MATERIALS AND METHODS

Patients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach-open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups.

RESULTS

A total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001).

CONCLUSIONS

This retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.

Robotic-assisted versus laparoscopic colectomy: cost and clinical outcomes

BACKGROUND AND OBJECTIVES

Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance.

METHODS

Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay.

RESULTS

Of 25,758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17,445 vs $15,448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001).

CONCLUSION

Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies.

A nationwide assessment comparing nonelective open with minimally invasive complex colorectal procedures

AIM

The use of minimally invasive colorectal surgery has increased greatly for both benign and malignant disease. Studies evaluating complex procedures have been largely limited to elective indications. We aimed to compare the outcome of a laparoscopic with an open transverse (TC) and total abdominal colectomy (TAC) in the nonelective setting.

METHOD

Comparative analysis was made using the Nationwide Inpatient Sample (2008-11) of patients undergoing a nonelective TC or TAC identified by ICD-9-CM procedure codes. The risk-adjusted 30-day outcome was assessed using regression modelling accounting for patient characteristics, comorbidity and surgical procedure.

RESULTS

We identified 7261 admissions including 818 laparoscopic and 6443 open procedures. The mean age of the population was 65 ± 17 years and patients in the laparoscopic group were younger (56 ± 20 vs. 66 ± 17 years; P < 0.05). The rate of a single complication was lower in the laparoscopic group (26% vs. 38%; P < 0.01), but this did not remain significant following a logistic regression analysis. Mortality was significantly lower in the laparoscopic group (3.1% vs. 17%; P < 0.01) and this remained true after adjusting for covariates (OR = 0.62; P < 0.05). Laparoscopic cases were associated with a shorter median length of stay (10 vs. 13 days; P < 0.01) and hospital charge ($75,758 vs. $98,833; P < 0.01).

CONCLUSION

A nonelective laparoscopic TC or TAC is associated with an equivalent complication rate and lower mortality compared with an open operation. The results should encourage surgeons with the appropriate skills to consider a laparoscopic approach for nonelective pathology requiring a complex colectomy.

Improved survival with early adjuvant chemotherapy after colonic resection for stage III colonic cancer: A nationwide study

BACKGROUND AND OBJECTIVES

In stage III colonic cancer, time from surgery to start of adjuvant chemotherapy may influence survival. In this study, we evaluated the effect of timing of adjuvant therapy on survival.

METHODS

Database study from the Danish Colorectal Cancer Group's national database. Data on patients with stage III colonic cancer operated between January 1, 2005 and August 31, 2012 were retrieved. Perioperative variables, surgical modality, and time to adjuvant therapy (<4, 4-8, or >8 weeks) were evaluated and Cox regression was performed to identify factors influencing survival.

RESULTS

The final population included 1,827 patients scheduled for adjuvant chemotherapy. Adjuvant therapy started within 4 and 8 weeks improved survival when compared to start later than 8 weeks (HR [95%CI]: 1.7 [1.1-2.6]; P = 0.024 and 1.4 [1.07-1.8]; P = 0.013, respectively), whereas there was no significant difference in survival with start after 4 versus 8 weeks (1.2 [0.8-1.8]; P = 0.37).

CONCLUSIONS

Survival increased when adjuvant therapy was started within 8 weeks after surgery for stage III colonic cancer.

National disparities in minimally invasive surgery for rectal cancer

BACKGROUND

Social and racial disparities have been identified as factors contributing to differences in access to care and oncologic outcomes in patients with colorectal cancer. The aim of this study was to investigate national disparities in minimally invasive surgery (MIS), both laparoscopic and robotic, across different racial, socioeconomic and geographic populations of patients with rectal cancer.

METHODS

We utilized the American College of Surgeons National Cancer Database to identify patients with rectal cancer from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Inclusion criteria included only one malignancy and no adjuvant therapy. Multivariate analysis was performed to investigate differences in age, gender, race, income, education, insurance coverage, geographic setting and hospital type in relation to the surgical approach.

RESULTS

A total of 8633 patients were identified. The initial surgical approach included 46.5% open (4016), 50.9% laparoscopic (4393) and 2.6% robotic (224). In evaluating type of insurance coverage, patients with private insurance were most likely to undergo laparoscopic surgery [OR (odds ratio) 1.637, 95% CI 1.178-2.275], although there was a less statistically significant association with robotic surgery (OR 2.167, 95% CI 0.663-7.087). Patients who had incomes greater than $46,000 and received treatment at an academic center were more likely to undergo MIS (either laparoscopic or robotic). Race, education and geographic setting were not statistically significant characteristics for surgical approach in patients with rectal cancer.

CONCLUSIONS

Minimally invasive approaches for rectal cancer comprise approximately 53% of surgical procedures in patients not treated with adjuvant therapy. Robotics is associated with patients who have higher incomes and private insurance and undergo surgery in academic centers.

Disparities in the Utilization of Laparoscopic Surgery for Colon Cancer in Rural Nebraska: A Call for Placement and Training of Rural General Surgeons

BACKGROUND

Advances in medical technology are changing surgical standards for colon cancer treatment. The laparoscopic colectomy is equivalent to the standard open colectomy while providing additional benefits. It is currently unknown what factors influence utilization of laparoscopic surgery in rural areas and if treatment disparities exist. The objectives of this study were to examine demographic and clinical characteristics associated with receiving laparoscopic colectomy and to examine the differences between rural and urban patients who received either procedure.

METHODS

This study utilized a linked data set of Nebraska Cancer Registry and hospital discharge data on colon cancer patients diagnosed and treated in the entire state of Nebraska from 2008 to 2011 (N = 1,062). Multiple logistic regression analysis was performed to identify predictors of receiving the laparoscopic treatment.

RESULTS

Rural colon cancer patients were 40% less likely to receive laparoscopic colectomy compared to urban patients. Independent predictors of receiving laparoscopic colectomy were younger age (<60), urban residence, ≥3 comorbidities, elective admission, smaller tumor size, and early stage at diagnosis. Additionally, rural patients varied demographically compared to urban patients.

CONCLUSIONS

Laparoscopic surgery is becoming the new standard of treatment for colon cancer and important disparities exist for rural cancer patients in accessing the specialized treatment. As cancer treatment becomes more specialized, the importance of training and placement of general surgeons in rural communities must be a priority for health care planning and professional training institutions.

Do the advantages of a minimally invasive approach remain in complex colorectal procedures? A nationwide comparison

BACKGROUND

Since the introduction of laparoscopic colectomy, experience and technology continue to improve. Although accepted for many colorectal conditions, its use and outcomes in complex procedures are less understood.

OBJECTIVE

The purpose of this work was to compare the perioperative outcomes of laparoscopic transverse colectomy and total abdominal colectomy (study group) with an open approach (comparative group) and the more established laparoscopic right, left, and sigmoid colectomies (control group).

DESIGN

This was a retrospective review of the Nationwide Inpatient Sample (2008-2011) of all patients undergoing elective right, left, sigmoid, total, or transverse colectomy as identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedures.

SETTINGS

The study included a national sample from a population database.

PATIENTS

There were 45,771 admissions: 2946 in the study group, 36,949 in the control group, and 5876 in the open comparative group.

MAIN OUTCOME MEASURES

Mortality was the primary outcome. Secondary outcomes included in-hospital complications, length of stay, and hospital charges.

RESULTS

The patients were predominantly white (73%), had private insurance (64%), and underwent surgery at urban centers (92%). Mortality was similar between the study and control groups (0.42% vs 0.51%; p = 0.52), with a higher complication rate in the study group (19% vs 14%; p < 0.01). The study group was also associated with a lower mortality rate compared with the open group (0.51% vs 2.20%; p < 0.01), which remained consistent after adjusting for covariates (OR, 0.38 [95% CI, 0.20-0.71]; p < 0.01). The study group had fewer complications overall compared with the open group (19% vs 27%; p < 0.01) and a shorter median length of stay (4.6 vs 6.3 days; p < 0.01).

LIMITATIONS

This was a retrospective study using an administrative database.

CONCLUSIONS

A laparoscopic approach for total abdominal and transverse colectomies has similar mortality rates and slightly higher complications than the more established laparoscopic colectomy procedures and improved perioperative outcomes when compared with an open technique (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A178).

Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: Analysis of a large prospective clinical database

BACKGROUND

Oncological outcomes of laparoscopic colon cancer surgery have been shown to be equivalent to those of open surgery, but only in the setting of randomized controlled trials on highly selected patients. The aim of this study is to investigate whether this finding is generalizable to real world practice.

METHODS

Analysis of prospectively collected data from the BioGrid Australia database was undertaken. Overall and cancer specific survival rates were compared with cox regression analysis controlling for the confounders of age, sex, BMI, ASA score, hospital site, year surgery performed, procedure, tumor stage, and adjuvant chemotherapy.

RESULTS

Between 2003 and 2009, 1,106 patients underwent elective colon cancer resection. There were differences between the laparoscopic and open cohorts in BMI, procedure, post-operative complication rate, and tumor stage. When baseline confounders were accounted for using cox regression analysis, there was no difference in 5 year overall survival (χ(2) test 1.302, P = 0.254), or cancer specific survival (χ(2) test 0.028, P = 0.866).

CONCLUSION

This large prospective clinical study validates previous trial results, and confirms that there is no difference in oncological outcome between laparoscopic and open surgery for colon cancer.

Evolution of technique in performance of minimally invasive colectomies

BACKGROUND

Hand-assisted laparoscopic surgery is commonly used in colorectal surgery and provides benefit in complex cases.

OBJECTIVE

This study examined the minimally invasive surgical trends, patient characteristics, and operative variables unique to patients undergoing hand-assisted laparoscopic surgery.

DESIGN

This was a retrospective medical chart review.

SETTINGS

The study was conducted in a tertiary care medical center.

PATIENTS

Patients included in the study were those who underwent pure laparoscopic colectomies, hand-assisted laparoscopic colectomies, and traditional open surgery for elective treatment of diverticular disease, colorectal cancer, IBD, and benign polyp disease.

MAIN OUTCOME MEASURES

Primary outcomes included patient characteristics and operative variables unique to patients undergoing hand-assisted laparoscopic surgery and documentation of operative technique trends within an experienced colorectal group.

RESULTS

Diverticular disease characteristics specific to hand-assisted laparoscopic surgery included the presence of dense inflammatory adhesions (p < 0.0001), diverticular fistulas (p < 0.0001), and unresolved phlegmon (p = 0.0003). Characteristics specific for colorectal cancer included intraoperative tumor bulk (p < 0.0001) and the inability to achieve appropriate surgical resection margins (p < 0.001). Similarly, variables identified for benign polyp disease included adhesions (p < 0.0001) and the ability to gain adequate exposure (p < 0.0001). Limited use of hand-assisted laparoscopic surgery was observed in patients with IBD.

LIMITATIONS

This was a retrospective, observational study from a single center.

CONCLUSIONS

Conversion to hand-assisted laparoscopic surgery provides benefit in surgical scenarios where dense inflammatory adhesions, diverticular fistulas, and intra-abdominal postdiverticulitis phlegmon are present. In addition, benefit is observed in patients with colorectal cancer where laparoscopic dissection of bulky tumor proves to be difficult and where the technical ability to obtain margins using pure laparoscopy is compromised. Although our practice has changed to favor pure laparoscopy, hand-assisted laparoscopic surgery continues to play an important role in complex colorectal cases that otherwise would require open surgery (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A146).

Fast track for elderly patients: is it feasible for colorectal surgery?

BACKGROUND

Fast-track program has been applied in several surgical fields. However, currently many surgical patients are elderly over 70 years of age, and discussion about the application of such protocols for elderly patients is inadequate.

MATERIALS AND METHODS

The present study was designed to consider the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients. A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast-track care program (n = 40) or the conventional perioperative care protocol (control group, n = 36). The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise. The length of postoperative hospital stay, the length of time to regain bowel function and the rate of postoperative complications were compared between the two groups.

RESULTS

The length of time to regain bowel function, including the passage of flatus [32 (24-40) h vs 42 (32-52) h], and to start a liquid diet (13 [10-16] h v/s 43 [36-50] h) were significantly shorter in patients receiving the fast track care protocol compared with those receiving the conventional care protocol. A shorter duration of postoperative hospital stay was recorded in patients receiving the fast-track program than in those receiving conventional care [6 (5-7) days v/s 9.5 (7-12) days]. A reduced percentage of patients who developed general complications was also observed in the fast-track group (5.0% v/s 18%).

CONCLUSION

Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared with a conventional postoperative protocol.

Early rehabilitation after surgery program versus conventional care during perioperative period in patients undergoing laparoscopic assisted total gastrectomy

OBJECTIVE

To evaluate the safety and efficacy of early rehabilitation after surgery program (ERAS) in patients undergoing laparoscopic assisted total gastrectomy.

MATERIALS AND METHODS

This is a study where 47 patients who are undergoing lap assisted total gastrectomy are selected. Twenty-two (n = 22) patients received enhanced recovery programme (ERAS) management and rest twenty-five (n = 25) conventional management during the perioperative period. The length of postoperative hospital stay, time to passage of first flatus, intraoperative and postoperative complications, readmission rate and 30 day mortality is compared. Serum levels of C-reactive protein pre-operatively and also on post-op day 1 and 3 are compared.

RESULTS

Postoperative hospital stay is shorter in ERAS group (78 ± 26 h) when compared to conventional group (140 ± 28 h). ERAS group passed flatus earlier than conventional group (37 ± 9 h vs. 74 ± 16 h). There is no significant difference in complications between the two groups. Serum levels of CRP are significantly low in ERAS group in comparison to conventional group. [d1 (52.40 ± 10.43) g/L vs. (73.07 ± 19.32) g/L, d3 (126.10 ± 18.62) g/L vs. (160.72 ± 26.18) g/L)].

CONCLUSION

ERAS in lap-assisted total gastrectomy is safe, feasible and efficient and it can ameliorate post-operative stress and accelerate postoperative rehabilitation in patients with gastric cancer. Short term follow up results are encouraging but we need long term studies to know its long term benefits.

Uptake and outcomes of laparoscopically assisted resection for colon and rectal cancer in Australia: a population-based study

BACKGROUND

Meta-analyses of randomized controlled trials support the use of laparoscopically assisted resection for colon cancer. The evidence supporting its use in rectal cancer is weak.

OBJECTIVE

The purpose of this work was to investigate the uptake of laparoscopically assisted resection for colon and rectal cancer and to compare short- and long-term outcomes using population data.

DESIGN

This was a retrospective cohort study using linked administrative health data.

SETTINGS

The study encompassed all of the public and private hospitals in New South Wales, Australia, between 2000 and 2008.

PATIENTS

A total of 27,947 patients with colon or rectal cancer undergoing surgery with curative intent were included in the study.

MAIN OUTCOME MEASURES

We summarized the proportion of resections performed laparoscopically. Short-term outcomes were extended stay, 28-day readmission, 28-day emergency readmission, 30- and 90-day mortality, and 90-day readmission with pulmonary embolism or deep-vein thrombosis. Long-term outcomes were all-cause and cancer-specific death and admission with obstruction or incisional hernia repair.

RESULTS

Laparoscopic procedures increased between 2000 and 2008 for colon (1.5%-20.7%) and rectal cancer (0.6%-15.5%). Laparoscopic procedures reduced rates of extended stay (OR, 0.60; 95% CI, 0.49-0.72) and 28-day readmission (OR, 0.86; 95% CI, 0.74-0.99) for colon cancer. For rectal cancer, laparoscopic procedures had lower rates of 28-day readmission (OR, 0.58; 95% CI, 0.42-0.78) and 28-day emergency readmission (OR, 0.54; 95% CI, 0.34-0.85). Laparoscopic procedures improved cancer-specific survival for rectal cancer (HR, 0.71; 95% CI, 0.51-1.00). Survival benefits were observed for laparoscopically assisted colon resection in higher-caseload hospitals but not lower-caseload hospitals.

LIMITATIONS

It was not possible to identify laparoscopically assisted resections converted to open procedures because of the claims-based nature of the data.

CONCLUSIONS

Despite increases in laparoscopically assisted resections for colon and rectal cancer, the majority of resections are still treated by open procedures. Our data suggest that laparoscopic resection reduces the lengths of stay and rates of readmission and may result in improved cancer-specific survival for both colon and rectal resections.

Comparison of the clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer

The present study aimed to compare the clinical outcomes of laparoscopic-assisted surgery versus open surgery for colorectal cancer and investigate the oncological safety and potential advantages and disadvantages of laparoscopic-assisted surgery for colorectal cancer. The medical records from a total of 160 patients who underwent surgery for colorectal cancer between January 2009 and January 2013 at The Second Hospital of Dalian Medical University (Dalian, China) were retrospectively analyzed. The patients who underwent laparoscopic-assisted surgery showed significant advantages due to the minimally invasive nature of the surgery compared with those who underwent open surgery, namely, less blood loss (P=0.002), shorter time to flatus (P<0.001), bowel movement (P=0.009) and liquid diet intake (P=0.015), earlier ambulation time (P=0.006), smaller length of incision (P<0.001) and a shorter post-operative hospital stay (P=0.007). However, laparoscopic-assisted surgery for colorectal cancer resulted in a longer operative time (P=0.015) and higher surgery expenditure (P=0.003) and total hospitalization costs (P<0.001) compared with open surgery. There were no statistically significant differences between the intraoperative and post-operative complications. There were no differences in the local recurrence (P=0.699) or distant metastasis (P=0.699) rates. In addition, no differences were found in overall survival (P=0.894) and disease-free survival (P=0.701). These findings indicated that laparoscopic-assisted surgery for colorectal cancer had the clear advantages of a minimally invasive surgery and relative disadvantages, including a longer surgery time and higher cost, and exhibited similar rates of recurrence and survival compared with open surgery.

Clinical outcomes of 103 hand-assisted laparoscopic surgeries for left-sided colon and rectal cancer: single institutional review

Purpose

The laparoscopic colectomy is avoided principally because of its technical difficulty, steep learning curve, and increased operative time. Hand-assisted laparoscopic surgery (HALS) is an alternative technique that addresses these problems while preserving the short-term benefits of a laparoscopic colectomy. Our study was aimed to describe the characteristics of patients admitted due to left-sided colon and rectal cancer for HALS.

Methods

A prospectively maintained database was used to identify patients who underwent HALS at the Institute of Oncology, Vilnius University, from July 1, 2009, to October 1, 2012.

Results

One hundred-three HALS colorectal resections were performed. The patients' mean age was 64 ± 13.4 years. There were 46 male and 57 female patients. The body mass index was 27.3 ± 5.8 kg/m². Forty-three patients (41.8%) had experienced prior abdominal surgery. The mean HALS time was 105 minutes (range, 55-85 minutes). The conversion rate was 2.7% (3/103). The median of return of gastrointestinal function was 2.5 days (range, 2.2-4.5 days). The median length of hospital stay was 9 days. The postoperative complication and mortality rates were 10.7% and 0.97%, respectively. Four incisional hernias (3.9%) were seen at a mean follow-up of 7.0 ± 3.4 months. None of the patients had a trocar or a hand-port site recurrence.

Conclusion

A HALS colorectal resection is a safe and effective technique, and it provides all the benefits of minimally invasive surgery.

National disparities in laparoscopic colorectal procedures for colon cancer

INTRODUCTION

Racial disparity in the treatment of colorectal cancer (CRC) has been cited as a potential cause for differences in mortality. This study compares the rates of laparoscopy according to race, insurance status, geographic location, and hospital size.

METHODS

The 2009 Healthcare Cost and Utilization Project: Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with the diagnosis of CRC by the International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariate logistic regression was performed to look at age, gender, insurance coverage, academic versus nonacademic affiliated institutions, rural versus urban settings, location, and proportional differences in laparoscopic procedures according to race.

RESULTS

A total of 14,502 patients were identified; 4,691 (32.35 %) underwent laparoscopic colorectal procedures and 9,811 (67.65 %) underwent open procedures. The proportion of laparoscopic procedures did not differ significantly by race: Caucasian 32.4 %, African-American 30.04 %, Hispanic 33.99 %, and Asian-Pacific Islander 35.12 (P = 0.08). Among Caucasian and African-American patients, those covered by private insurers were more likely to undergo laparoscopic procedures compared to other insurance types (P ≤ 0.001). The odds of receiving laparoscopic procedure at teaching hospitals was 1.39 times greater than in nonteaching hospitals (95 % confidence interval [CI] 1.29-1.48) and did not differ across race groups. Patients in urban hospitals demonstrated higher odds of laparoscopic surgery (2.24, 95 % CI 1.96-2.56) than in rural hospitals; this relationship was consistent within races. The odds of undergoing laparoscopic surgeries was lowest in the Midwest region (0.89, 95 % CI 0.81-0.97) but higher in the Southern region (1.14, 95 % CI 1.06-1.22) compared with the other regions.

CONCLUSIONS

Nearly one-third of all CRC surgeries are laparoscopic. Race does not appear to play a significant role in the selection of a laparoscopic CRC operation. However, there are significant differences in the selection of laparoscopy for CRC patients based on insurance status, geographic location, and hospital type.