Evaluating the Regional Uptake of Minimally Invasive Colorectal Surgery: a Report from the Surgical Care Outcomes Assessment Program

"Impact of regional data reporting and feedback on rectal cancer surgery quality metrics in the Surgical Care Outcomes Assessment Program (SCOAP)"

Background

Management of rectal cancer is increasingly complex. Leading societies describe metrics of high-quality perioperative rectal cancer care with the goal of reducing variation in practice and improving outcomes. This study was designed to describe the impact of targeted feedback at the institutional level on improving achievement of rectal cancer quality metrics.

Methods

Adult elective rectal cancer resections performed at institutions that continuously participated in SCOAP between 2011 and 2022 were included for analysis. Quality metrics evaluated were preoperative MRI (MRI), determination of tumor location (TL), use of neoadjuvant chemoradiation (NAC), performance of a total mesorectal excision (TME), 12+ lymph nodes resected (LN), and composite negative margins (NM). In-depth feedback on these metrics was provided by SCOAP at the end of 2015 and 2019. Achievement of the metrics was evaluated before (2011-2016), between (2017-2019), and after (2020-2022) feedback events to determine effect on achievement.

Results

1962 resections were performed at 19 institutions. There were statistically significant increases in MRI(2011-2016 = 32 %, 2017-2019 = 88 %, 2020-2022 = 92 %;p < 0.01), TME(47 %, 68 %, 80 %;p < 0.01), and LN(76 %, 86 %, 86 %;p < 0.01) after one or both feedback events. TL(67 %, 69 %, 70 %;p = 0.558), NAC(62 %, 63 %, 67 %;p = 0.124), and NM(98 %, 97 %, 96 %;p = 0.39) were not significantly different. Mean composite score for metrics increased after each feedback (2011-2016 = 3.8±1.4; 2017-2019 = 4.3±1.4; 2020-2022 = 4.5±1.5;p < 0.01).

Conclusion

Interval, in-depth feedback on rectal cancer quality process metrics was associated with increased achievement of several metrics and overall number of metrics achieved. Broader implementation of this feedback method could further advance the quality of rectal cancer surgical care.

Surgical Approach and Variation in Long-Term Survival Following Colorectal Cancer Surgery Using Instrumental Variable Analysis

Objective

The study aimed to determine whether increased use of minimally invasive surgical approaches, compared with open, improves long-term survival after colon and rectal cancer resections.

Background

Existing prospective and observational data comparing surgical approach for colon and rectal cancer are limited by selection bias, necessitating better approaches for causal inference to understand the relationship between surgical approach and long-term survival.

Methods

We included colon and rectal cancer patients who underwent colon or rectal resection from the American College of Surgeons National Cancer Database between 2011 and 2018. Using an instrumental variable (IV) approach, we accounted for measured and unmeasured differences between patients undergoing colon or rectal cancer resection based on operative approach - robotic, laparoscopic, or open. The IV used in this study was rate of robotic-assisted colon and rectal cancer surgery within 81 different hospital regions based on US Census region and rurality during the 12 months before each patient's operation. Proportional hazard modeling was used to estimate risk-adjusted mortality rates.

Results

There were 326,406 colon and 96,979 rectal cancer patients included in this study. The risk-adjusted 5-year cumulative incidence of mortality for colon and rectal cancer was highest for patients who underwent open approaches (35.73 [95% confidence interval {CI}: 35.37-36.1] and 39.27 [95% CI: 28.44-30.13], respectively), compared with lower mortality for those undergoing laparoscopic (28.91 [95% CI: 28.55-29.27] and 22.93 [95% CI: 22.11-23.78], respectively) and robotic approaches (26.39 [95% CI: 24.51-28.42] and 19.77 [95% CI: 17.32-22.43], respectively). Growth in utilization of minimally invasive approaches outpaced improvements in long-term survival.

Conclusions

Patients undergoing minimally invasive surgical approaches for colon and rectal cancer had improved long-term survival. However, long-term survival changes did not correlate with the large expansion of minimally invasive approaches, which suggests that growing these approaches is not a viable strategy to improve long-term patient outcomes.

Histopathological outcomes of transanal, robotic, open, and laparoscopic surgery for rectal cancer resection. A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed.

RESULTS

The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I2:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I2:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I2:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I2:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved.

CONCLUSION

When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.

An artificial intelligence-designed predictive calculator of conversion from minimally invasive to open colectomy in colon cancer

Minimally invasive surgery is safe and effective in colorectal cancer. Conversion to open surgery may be associated with adverse effects on treatment outcomes. This study aimed to assess risk factors of conversion from minimally invasive to open colectomy for colon cancer and impact of conversion on short-term and survival outcomes. This case-control study included colon cancer patients undergoing minimally invasive colectomy from the National Cancer Database (2015-2019). Logistic regression analyses were conducted to determine independent predictors of conversion from laparoscopic and robotic colectomy to open surgery. 26,546 patients (mean age: 66.9 ± 13.1 years) were included. Laparoscopic and robotic colectomies were performed in 79.1% and 20.9% of patients, respectively, with a 10.6% conversion rate. Independent predictors of conversion were male sex (OR: 1.19, p = 0.014), left-sided cancer (OR: 1.35, p < 0.001), tumor size (OR: 1, p = 0.047), stage II (OR: 1.25, p = 0.007) and stage III (OR: 1.47, p < 0.001) disease, undifferentiated carcinomas (OR: 1.93, p = 0.002), subtotal (OR: 1.25, p = 0.011) and total (OR: 2.06, p < 0.001) colectomy, resection of contiguous organs (OR: 1.9, p < 0.001), and robotic colectomy (OR: 0.501, p < 0.001). Conversion was associated with higher 30- and 90-day mortality and unplanned readmission, longer hospital stay, and shorter overall survival (59.8 vs 65.3 months, p < 0.001). Male patients, patients with bulky, high-grade, advanced-stage, and left-sided colon cancers, and patients undergoing extended resections are at increased risk of conversion from minimally invasive to open colectomy. The robotic platform was associated with reduced odds of conversion. However, surgeons' technical skills and criteria for conversion could not be assessed.

Use of Simulation For Training Advanced Colorectal Procedures

OBJECTIVE

Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC).

DESIGN

LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri.

PARTICIPANTS

Senior general surgery residents at large academic surgery program.

RESULTS

Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts.

CONCLUSIONS

Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

Outcome of Laparoscopic Versus Open Appendectomy for Acute Appendicitis-Results of a Propensity Score Matching Analysis of 542 Patients and Consequences for the Military Surgeon

INTRODUCTION

Appendectomy is the treatment of choice for acute appendicitis. The procedure can be performed open or laparoscopically. However, laparoscopy is not available on military missions abroad. It is unclear whether treatment outcomes differ between the two surgical approaches.

MATERIALS AND METHODS

Treatment data of all patients undergoing open and laparoscopic appendectomies in the German Armed Forces Hospital of Ulm from 2013 to 2017 were collected retrospectively. A propensity score matching analysis was performed to minimize the influence of potential confounders and to assess the influence of surgical approach on outcome (reoperations, superficial and deep surgical infections, length of postoperative ileus, need for intravenous analgesics, and operative time).

RESULTS

A total of 542 patients with complete datasets were included in the propensity score matching analysis, among these 64 with open and 478 laparoscopic procedures. There were no statistically significant differences between open and laparoscopic surgeries with respect to all outcome variables, with the exception of a 25-minute prolonged operative time for the open approach.

CONCLUSIONS

Open appendectomy can be considered equivalent in outcome to the laparoscopic procedure and thus can be performed on military missions abroad without compromising outcome. Military surgeons must continue to be trained and confident in open appendectomy.

The Impact of Prolonged Operative Time Associated With Minimally Invasive Colorectal Surgery: A Report From the Surgical Care Outcomes Assessment Program

BACKGROUND

Increased operative time in colorectal surgery is associated with worse surgical outcomes. Laparoscopic and robotic operations have improved outcomes, despite longer operative times. Furthermore, the definition of "prolonged" operative time has not been consistently defined.

OBJECTIVE

The first objective was to define prolonged operative time across multiple colorectal operations and surgical approaches. The second was to describe the impact of prolonged operative time on length of stay and short-term outcomes.

DESIGN

A retrospective cohort study.

SETTING

Forty-two hospitals in the Surgical Care Outcomes Assessment Program from 2011 to 2019.

PATIENTS

There were a total of 23,098 adult patients (age 18 years or older) undergoing 6 common, elective colorectal operations: right colectomy, left/sigmoid colectomy, total colectomy, low anterior resection, IPAA, or abdominoperineal resection.

MAIN OUTCOME MEASURES

Prolonged operative time defined as the 75th quartile of operative times for each operation and approach. Outcomes were length of stay, discharge home, and complications. Adjusted models were used to account for factors that could impact operative time and outcomes across the strata of open and minimally invasive approaches.

RESULTS

Prolonged operative time was associated with longer median length of stay (7 vs 5 days open, 5 vs 4 days laparoscopic, 4 vs 3 days robotic) and more frequent complications (42% vs 28% open, 24% vs 17% laparoscopic, 27% vs 13% robotic) but similar discharge home (86% vs 87% open, 94% vs 94% laparoscopic, 93% vs 96% robotic). After adjustment, each additional hour of operative time above the median for a given operation was associated with 1.08 (1.06-1.09) relative risk of longer length of stay for open operations and 1.07 (1.06-1.09) relative risk for minimally invasive operations.

LIMITATIONS

Our study was limited by being retrospective, resulting in selection bias, possible confounders for prolonged operative time, and lack of statistical power for subgroup analyses.

CONCLUSIONS

Operative time has consistent overlap across surgical approaches. Prolonged operative time is associated with longer length of stay and higher probability of complications, but this negative effect is diminished with minimally invasive approaches. See Video Abstract .

EL IMPACTO DEL TIEMPO OPERATORIO PROLONGADO ASOCIADO CON LA CIRUGA COLORRECTAL MNIMAMENTE INVASIVA UN INFORME DEL PROGRAMA DE EVALUACIN DE RESULTADOS DE ATENCIN QUIRRGICA

ANTECEDENTES:El aumento del tiempo operatorio en la cirugía colorrectal se asocia con peores resultados quirúrgicos. Las operaciones laparoscópicas y robóticas han mejorado los resultados, a pesar de los tiempos operatorios más prolongados. Además, la definición de tiempo operatorio "prolongado" no se ha definido de manera consistente.OBJETIVO:Primero, definir el tiempo operatorio prolongado a través de múltiples operaciones colorrectales y enfoques quirúrgicos. En segundo lugar, describir el impacto del tiempo operatorio prolongado sobre la duración de la estancia y los resultados a corto plazo.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:42 hospitales en el Programa de Evaluación de Resultados de Atención Quirúrgica de 2011-2019.PACIENTES:23 098 pacientes adultos (de 18 años de edad y mayores), que se sometieron a seis operaciones colorrectales electivas comunes: colectomía derecha, colectomía izquierda/sigmoidea, colectomía total, resección anterior baja, anastomosis ileoanal con bolsa o resección abdominoperineal.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio prolongado definido como el cuartil 75 de tiempos operatorios para cada operación y abordaje. Los resultados fueron la duración de la estancia hospitalaria, el alta domiciliaria y las complicaciones. Se usaron modelos ajustados para tener en cuenta los factores que podrían afectar tanto el tiempo operatorio como los resultados en los estratos de abordajes abiertos y mínimamente invasivos.RESULTADOS:El tiempo operatorio prolongado se asoció con una estancia media más prolongada (7 vs. 5 días abiertos, 5 vs. 4 días laparoscópicos, 4 vs. 3 días robóticos), complicaciones más frecuentes (42 % vs. 28 % abiertos, 24 % vs. 17 % laparoscópica, 27% vs. 13% robótica), pero similar alta domiciliaria (86% vs. 87% abierta, 94% vs. 94% laparoscópica, 93% vs. 96% robótica). Después del ajuste, cada hora adicional de tiempo operatorio por encima de la mediana para una operación determinada se asoció con un riesgo relativo de 1,08 (1,06, 1,09) de estancia hospitalaria más larga para operaciones abiertas y un riesgo relativo de 1,07 (1,06, 1,09) para operaciones mínimamente invasivas.LIMITACIONES:Nuestro estudio estuvo limitado por ser retrospectivo, lo que resultó en un sesgo de selección, posibles factores de confusión por un tiempo operatorio prolongado y falta de poder estadístico para los análisis de subgrupos.CONCLUSIONES:El tiempo operatorio tiene una superposición constante entre los enfoques quirúrgicos. El tiempo operatorio prolongado se asocia con una estadía más prolongada y una mayor probabilidad de complicaciones, pero este efecto negativo disminuye con los enfoques mínimamente invasivos. ( Traducción-Dr. Mauricio Santamaria ).

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Efficacy of laparoscopic surgery for loop colostomy: a propensity-score-matched analysis

PURPOSE

Colostomy is a common procedure for fecal diversion, but the optimal colostomy approach is unclear in terms of surgical outcomes and stoma-related complications. The purpose of this study was to examine the efficacy and feasibility of laparoscopic loop colostomy.

METHODS

This retrospective cohort study included patients who underwent loop colostomy at Shizuoka Cancer Center in Japan between April 2010 and March 2022. Patients were divided into two groups based on surgical approach: the laparoscopic (LAP) and open (OPEN) groups. Surgical outcomes and the incidences of stoma-related complications such as stomal prolapse (SP), parastomal hernia (PSH), and skin disorders (SD) were compared with and without propensity score matching.

RESULTS

Of the 388 eligible patients, 180 (46%) were in the LAP group and 208 (54%) were in the OPEN group. The male-to-female ratio was 5.5:4.5 in the Lap group and was 5.3:4.7 in the OPEN group, respectively. The median age was 68 years (range, 31-88 years) in the LAP group and 65 years (range, 23-93 years) in the OPEN group, respectively. The LAP group, compared with the OPEN group, had a shorter operative time and lower incidences of surgical site infection (3.9% versus 16.3%, respectively; p < 0.01) and SD (11.7% versus 24.5%, respectively; p < 0.01). There was no significant difference between the LAP and OPEN groups in the incidence of SP (17.3% versus 17.3%, respectively) or PSH (8.9% versus 6.7%, respectively). After propensity score matching, the incidences of surgical site infection and SD were significantly lower in the LAP group than in the OPEN group, while there were no significant differences in the operative time or the incidences of SP and PSH.

CONCLUSION

Our results suggest that laparoscopic surgery could be beneficial and feasible in loop colostomy.

Implementation of a structured robotic colorectal curriculum for general surgery residents

There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.

Clinical and Economic Burden Associated with Disruptive Surgical Bleeding: A Retrospective Database Analysis

Background

Hemostatic agents are used to control surgical bleeding; however, some patients experience disruptive bleeding despite the use of hemostats. In patients receiving hemostats, we compared clinical and economic outcomes between patients with vs without disruptive bleeding during a variety of surgical procedures.

Methods

This was a retrospective analysis of the Premier Healthcare Database. Study patients were age ≥18 with a hospital encounter for one of 9 procedures with evidence of hemostatic agent use between 1-Jan-2019 and 31-Dec-2019: cholecystectomy, coronary artery bypass grafting (CABG), cystectomy, hepatectomy, hysterectomy, pancreatectomy, peripheral vascular, thoracic, and valve procedures (first procedure = index). Patients were grouped by presence vs absence of disruptive bleeding. Outcomes evaluated during index included intensive care unit (ICU) admission/duration, ventilator use, operating room time, length of stay (LOS), in-hospital mortality, and total hospital costs; 90-day all-cause inpatient readmission was also evaluated. Multivariable analyses were used to examine the association of disruptive bleeding with outcomes, adjusting for patient, procedure, and hospital/provider characteristics.

Results

The study included 51,448 patients; 16% had disruptive bleeding (range 1.5% for cholecystectomy to 44.4% for valve). In procedures for which ICU and ventilator use is not routine, disruptive bleeding was associated with significant increases in the risks of admission to ICU and requirement for ventilator (all p≤0.05). Across all procedures, disruptive bleeding was also associated with significant incremental increases in days spent in ICU (all p≤0.05, except CABG), LOS (all p≤0.05, except thoracic), and total hospital costs (all p≤0.05); 90-day all-cause inpatient readmission, in-hospital mortality, and operating room time were higher in the presence of disruptive bleeding and varied in statistical significance across procedures.

Conclusion

Disruptive bleeding was associated with substantial clinical and economic burden across a wide variety of surgical procedures. Findings emphasize the need for more effective and timely intervention for surgical bleeding events.

Health-care expenditures are less for minimally invasive than open colectomy for colon cancer: A US commercial claims database analysis

BACKGROUND

Most studies comparing surgical platforms focus on short-term outcomes. In this study, we compare the expanding societal penetration of minimally invasive surgery (MIS) with open colectomy by assessing payer and patient expenditures up to one year for patients undergoing surgery for colon cancer.

METHODS

We analyzed the IBM MarketScan Database for patients who underwent left or right colectomy for colon cancer between 2013 and 2020. Outcomes included perioperative complications and total health-care expenditures up to 1 year following colectomy. We compared results for patients who had open colectomy (OS) to those with MIS operations. Subgroup analyses were performed for adjuvant chemotherapy (AC+) versus no adjuvant chemotherapy (AC-) groups and for laparoscopic (LS) versus robotic (RS) approaches.

RESULTS

Of 7,063 patients, 4,417 cases did not receive adjuvant chemotherapy (OS: 20.1%, LS: 67.1%, RS: 12.7%) and 2646 cases had adjuvant chemotherapy (OS: 28.4%, LS: 58.7%, RS: 12.9%) after discharge. MIS colectomy was associated with lower mean expenditure at index surgery and post-discharge periods for AC- patients (index surgery: $34,588 vs $36,975; 365-day post-discharge $20,051 vs $24,309) and for AC+ patients (index surgery: $37,884 vs $42,160; 365-day post-discharge $103,341vs $135,113; p < 0.001 for all comparisons). LS had similar index surgery expenditures but significantly higher expenditures at post-discharge 30 days (AC-: $2,834 vs $2276, p = 0.005; AC+: $9100 vs $7698, p = 0.020) than RS. The overall complication rate was significantly lower in the MIS group than the open group for AC- patients (20.5% vs 31.2%) and AC+ patients (22.6% vs 39.1%, both p < 0.001).

CONCLUSION

MIS colectomy is associated with better value at lower expenditure than open colectomy for colon cancer at the index operation and up to one year after surgery. RS expenditure is less than LS in the first 30 postoperative days regardless of chemotherapy status and may extend to 1 year for AC- patients.

Feasibility of two laparoscopic surgeries for colon cancer performed by the same surgeon on a single day

BACKGROUND

Although the proportion of laparoscopic colectomies (LCs) for colon cancer is increasing, the feasibility of the same surgeon performing two LCs on a single day remains unknown. This study was conducted to clarify the feasibility of this practice by evaluating short-term and long-term outcomes.

METHODS

This retrospective analysis enrolled patients with pathological stage I-III colon cancer who underwent LC at the Shizuoka Cancer Center between 2010 and 2020. Patients were divided into two groups based on the timing of the surgery for the surgeon. The first group (n = 1485) comprised patients who underwent LC as the first surgery of the day for the surgeon. The second group (n = 163) comprised patients who underwent LC as the second LC of the day for the surgeon. Propensity score matching was performed to balance the baseline characteristics of the first and second groups. The short-term and long-term outcomes of the two groups were compared.

RESULTS

After propensity score matching, there were no significant differences in the incidence of postoperative complications of Clavien-Dindo classification grade II or higher between the first (10.4%, 17/163) and second groups (5.5%, 9/163). There were no significant differences in other perioperative outcomes, including operative time, intraoperative blood loss, and incidence of conversion to open surgery, between the two groups. Regarding long-term outcomes, there were no significant differences in overall survival or relapse-free survival between the two groups both in the full cohort and in the propensity score-matched cohort. In the propensity score-matched cohort, 5-year overall survival was 92.7% in the first group and 94.4% in the second group; 5-year relapse-free survival was 87.1% and 90.3%, respectively.

CONCLUSION

Our results suggest that the same surgeon performing two LCs for colon cancer on a single day is feasible in terms of short-term and long-term outcomes.

Feasibility of injected indocyanine green for ureteral identification during robotic left-sided colorectal resections

BACKGROUND

Ureteral identification is essential to performing safe colorectal surgery. Injected immunofluorescence may aid with ureteral identification, but feasibility without ureteral catheterization is not well described.

METHODS

Case series of robotic colorectal resections where indocyanine green (ICG) injection with or without ureteral catheter placement was performed. Imaging protocol, time to ureteral identification, and factors impacting visualization are reported.

RESULTS

From 2019 to 2020, 83 patients underwent ureteral ICG injection, 20 with catheterization and 63 with injection only. Main indications were diverticulitis (52%) and cancer (36%). Median time to instill ICG was faster with injection alone than with catheter placement (4min vs 13.5min, p < 0.001). Median time [IQR] to right ureter (0.3 [0.01-1.2] min after robot docking) and left ureter (5.5 [3.1-8.8] min after beginning dissection) visualization was not different between injection alone and catheterization.

CONCLUSION

ICG injection alone is faster than with indwelling catheter placement and equally reliable at intraoperative ureteral identification.

The impact of obesity on minimally invasive colorectal surgery: A report from the Surgical Care Outcomes Assessment Program collaborative

BACKGROUND

Operating on obese patients can increase case complexity and result in worse outcomes. We described the incremental impact of BMI on morbidity and outcomes of colorectal operations and whether laparoscopic and robotic(MIS) approaches mitigate this morbidity differently.

METHODS

A retrospective cohort of patients undergoing elective colorectal operations in SCOAP was created to examine the association of increasing BMI on surgical outcomes. Additionally, multivariable logistic regression models were constructed.

RESULTS

From 2011 to 2019, 22,863 elective colorectal operations (mean age 62, 55% female) were performed at 42 hospitals. Patients had BMI≥30 in 7576(33%) and BMI≥40 in 1180(5%) of operations. After risk adjustment, BMI≥40 was associated with increased conversions(OR1.57,95%CI1.26-1.96), increased combined adverse events(CAE)(OR1.32,95%CI1.15-1.52), and death(OR2.24, 95%CI1.41-3.55)(all p < 0.01). MIS approaches were each associated with lower CAE(lap OR0.49,95%CI0.46-0.53; robot OR0.42,95%CI0.37-0.47), and death(lap OR0.24,95%CI0.18-0.33; robot OR0.18,95%CI0.10-0.35)(all p < 0.01).

CONCLUSIONS

Severe obesity is associated with increased conversion rates and worse short-term outcomes after colorectal surgery, though this trend is partially mitigated with a minimally invasive approach. These findings support the broad application of MIS for colorectal operations in obese patients.