A population-based comparison of open versus minimally invasive abdominoperineal resection

Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis

BACKGROUND

Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection.

OBJECTIVE

The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy.

DESIGN

Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters.

SETTING

A decision model using a Markov model was designed.

PATIENTS

The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy.

MAIN OUTCOME MEASURES

Life-years and quality-adjusted life-years were measured.

RESULTS

Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality.

LIMITATIONS

The study was limited by assumptions inherent to modeling studies.

CONCLUSIONS

Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.

Clinical Research Using the National Inpatient Sample: A Brief Review of Colorectal Studies Utilizing the NIS Database

The National Inpatient Sample (NIS) is the largest collection of longitudinal hospital care data in the United States and is sponsored by the Agency for Healthcare Research and Quality. The data are collected from state organizations, hospital associations, private organizations, and the federal government. This database has been used in more than 400 disease-focused studies to examine health care utilization, access, charges, quality, and outcomes of care. The database has been maintained since 1988, making it one of the oldest on hospital data. The focus of this review is to explore and discuss the use of NIS database in colorectal surgery research and to formulate a simplified guide of the data captured for future researchers.

Frequency and timing of short-term complications following abdominoperineal resection

BACKGROUND

Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have become more popular. The differences in short-term complications between open and laparoscopic APR are poorly characterized.

METHODS

We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to determine the frequency and timing of onset of 30-d postoperative complications after APR and identify differences between open and laparoscopic APR.

RESULTS

A total of 7681 patients undergoing laparoscopic or open APR between 2011 and 2015 were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). Laparoscopic APR was associated with a 14% lower total complication rate compared to open APR (36.0% versus 50.1%, P < 0.001). This was primarily driven by a decreased rate of transfusion (10.7% versus 24.9%, P < 0.001) and surgical site infection (15.5% versus 21.2%, P < 0.001). Laparoscopic APR had shorter length of stay and decreased reoperation rate but similar rates of readmission and death. Cardiopulmonary complications occurred earlier in the postoperative period after APR, whereas infectious complications occurred later.

CONCLUSIONS

Short-term complications following APR are common and occur more frequently in patients who undergo open APR. This, along with factors such as risk of positive pathologic margins, surgeon skill set, and patient characteristics, should contribute to the decision-making process when planning rectal cancer surgery.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Best Approach and Benefit of Plication for Paralyzed Diaphragm

Diaphragmatic eventration and diaphragmatic paralysis are 2 entities with different etiology and pathology, and are often clinically indistinguishable. When symptomatic, their treatment is the same, with the objective to reduce the dysfunctional cephalad excursion of the diaphragm during inspiration. This can be achieved with diaphragmatic plication through the thorax or the abdomen with either open or minimally invasive techniques. We prefer the laparoscopic approach, due to its easy access to the diaphragm and to avoid pain associated with intercostal incisions and instrument use. Short-term and long-term results are excellent with this technique.

Laparoscopic resection of rectal cancer in the elderly

Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population. Thus, laparoscopic resection of rectal cancer remains a viable option for the elderly.

Radiochemotherapy Versus Surgery in Nonmetastatic Anorectal Neuroendocrine Carcinoma: A Multicenter Study by the Association des Gastro-Entérologues Oncologues

Neuroendocrine carcinomas (NEC) of the anus or the rectum are a rare disease, accounting for less than 1% of all digestive malignancies. Most are metastatic at diagnosis and treated with a platinum-based chemotherapy. No guidelines for localized tumors exist. The purpose of this study was to describe the characteristics of anorectal localized NEC, their management and their outcomes.We retrospectively reviewed patients from 11 French centers with anorectal localized NEC. We compared 2 therapeutic managements: surgery (group A) versus chemotherapy with or without radiation (group B). Progression-free survival (PFS) and overall survival (OS) were estimated with the Kaplan-Meier method.A total of 24 patients were identified with a median follow-up of 25 months (3-60 months). Median age was 63 years old and 17 had a rectal tumor (71%). Mean Ki-67 was 72% (range: 20-100), and 75% of the tumors had a high proliferative index (Ki-67 > 50%). Global PFS and OS were 13.1 and 44.1 months, respectively. Thirty-seven percent of patients were in group A and 63% in group B. There was no difference between group A and group B, whether in terms of PFS (13.0 months vs. 13.2 months, P = 0.75) or OS (49.1 months vs. 39.2 months, P = 0.42).In patients with anorectal localized NEC, chemotherapy with or without radiation obtained a similar outcome as surgery and this conservative approach could be deemed a reasonable option.