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

Anesthetic Considerations for Robotic Liver Transplantation

Liver transplantation has traditionally been performed through a large, bilateral subcostal incision. Recently, liver transplant programs across the world, including our own, have reported successful liver transplants via total robotic approaches on recipients with low Model for End-stage Liver Disease scores and preexisting abdominal wall laxity. This review discusses the unique anesthetic considerations of robotic liver transplantation based on our group's initial experience with this novel surgical approach. Robotic liver transplantation presents a unique set of considerations and challenges for the anesthesiologist, and a thorough understanding of liver disease, liver transplant surgery, venovenous bypass, and the various implications of robotic surgery is essential to ensure optimal patient outcomes. Specific management topics discussed here include appropriate patient selection, preoperative assessment, and intraoperative management. We also discuss certain theoretical and actual challenges that our group has experienced.

Robotic versus laparoscopic colorectal surgery for patients with obesity: an updated systematic review and meta-analysis

BACKGROUND

Obesity poses significant challenges in colorectal surgery, affecting operative difficulty and postoperative recovery. The choice of minimally invasive approach for this patient population remains a challenge during preoperative planning. This review aims to provide an updated synthesis of studies comparing laparoscopic and robotic approaches for adult patients with obesity undergoing colorectal surgery.

METHODS

MEDLINE, Embase and CENTRAL were searched up to August 2023. Articles were included if they compared laparoscopic and robotic colorectal surgery outcomes in adults with obesity (BMI ≥30 kg/m2). Outcomes included overall postoperative morbidity, conversion to laparotomy, and operative time. Inverse variance random-effects meta-analyses were used to pool effect estimates.

RESULTS

After screening 2187 citations, 10 observational studies were included with 3281 patients with obesity undergoing robotic surgery (mean age: 58.1 years, female: 43.9%) and 11 369 patients with obesity undergoing laparoscopic surgery (mean age: 58 years, female: 53.2%). Robotic surgery resulted in longer operative times (MD 46.71 min, 95% CI 33.50-59.92, p < 0.01, I2 = 93.79%) with statistically significant reductions in conversions to laparotomy (RR 0.50, 95% CI 0.39-0.65, p < 0.01, I2 = 67.15%). No significant differences were seen in postoperative morbidity (RR 0.94, 95% CI 0.82-1.08, p = 0.40, I2 = 36.08%).

CONCLUSION

These data suggest that robotic colorectal surgery in patients with obesity may reduce the risk for conversion to laparotomy, but at the expense of increased operative times and with no overt benefits in postoperative outcomes. Further high quality randomized controlled trials assessing the utility of robotic surgery in patients with obesity undergoing colorectal surgery are warranted.

Does robotic assisted surgery mitigate obesity related systemic inflammatory response and clinical outcomes in left sided colorectal cancer resections?

Obesity (BMI > 30 kg/m2) is rapidly increasing worldwide with 26% of the UK population being obese and 38% being overweight. Obesity is intimately related to several life-limiting conditions including colorectal cancer (CRC). Obese patients have a higher degree of perioperative systemic inflammatory response (SIR) and an increased risk of perioperative complications. The aim of this current study was to investigate whether robotic-assisted surgery mitigates the effects of obesity in left sided CRC resections on the SIR and clinical outcomes. All patients undergoing left-sided colorectal cancer resections from May 2021 to May 2023 were, prospectively, entered into a database with patient characteristics and perioperative short-term outcomes recorded. CRP was considered a surrogate for SIR. The relationship between obesity and complications were examined using Chi Square for linear association, Kruskal-Wallis for continuous data and multivariate binary logistic regression model. 221 patients who underwent RAS for left-sided CRC were analysed. Obesity was associated with more comorbidity (ASA, p < 0.01) and SSI (p < 0.05) but not with age, sex, procedure or pathology. POD3 CRP < 150 mg/l was also associated with obesity (p < 0.01). In turn, greater comorbidity was associated with age (p < 0.001), site of resection (p < 0.05), SSI (p < 0.05), postoperative blood transfusion (p < 0.01) and LOS (p < 0.001). On multivariate analysis, only greater ASA (p < 0.05) and surgical procedure (p < 0.01) were associated with the development of an SSI independently. Greater comorbidity but not obesity was independently associated with postoperative SIR and clinical outcomes in patients undergoing RAS. These results support the use of RAS for left sided CRC resections, particularly in the obese.

"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.

Impact of Obesity on the Outcomes of Supine Percutaneous Nephrolithotomy: A Propensity Score Analysis

Objectives: The aim of this study was to evaluate whether obesity could influence the success and safety of percutaneous nephrolithotomy (PCNL) performed in the supine position. Patients and Methods: This prospective cohort study included 664 patients who underwent supine PCNL between September 2008 and June 2023. Patients were stratified into two groups: obese (272 patients) and nonobese (392 patients). To minimize bias, a 1:1 matching was performed between the groups based on Guy's stone score, preoperative stone burden, and potential confounding variables. Procedural success was defined as the complete absence of stones on CT performed 3 months postoperatively. Safety was assessed by the incidence of overall, infectious, and hemorrhagic complications, with complications graded using the modified Clavien-Dindo classification. Results: The obese patient group showed a significantly higher prevalence of hypertension, diabetes mellitus, and higher anesthetic risk according to the American Society of Anesthesiologists' classification. However, the complexity of the cases and the surgical technique employed were compared between the two groups. In the univariate analysis, no significant differences were observed in success rates (p = 0.118), overall complications (p = 0.222), hemorrhagic (p = 0.104), or infectious complications (p = 0.326). After matching, a significant reduction in hemorrhagic complications was identified in the obese patient group (odds ratio 0.43; 95% confidence interval: 0.18-0.97; p = 0.027). However, obesity was not associated with an increased likelihood of overall (p = 0.093) or infectious complications (p = 0.869), nor did it affect procedural success (p = 0.219). Conclusions: Obesity should not compromise the success or safety of PCNL when performed in the supine position. On the contrary, it may offer a protective effect against hemorrhagic complications. These findings suggest that supine PCNL is a safe and effective surgical option for obese patients, and obesity should not be regarded as a contraindication when the procedure is otherwise indicated.

Challenges and Strategies in Colorectal Surgery among Patients with Morbid Obesity

This chapter explores the interplay between morbid obesity and the challenges encountered in colorectal surgery. Understanding the unique considerations in preoperative and intraoperative management along with weight optimization tools such as bariatric surgery emerges as potential mitigators, demonstrating benefits in reducing colorectal cancer risk and improving perioperative outcomes. Furthermore, the pervasive stigma associated with morbid obesity further complicates patient care, emphasizing the need for empathetic and nuanced approaches. Recommendations for minimizing stigma involve recognizing obesity as a medical diagnosis, fostering respectful communication, and actively dispelling misconceptions. Colorectal surgeons are pivotal in navigating these complexities, ensuring comprehensive and tailored care for patients with morbid obesity.

Is the NICE procedure the great equalizer for patients with high BMI undergoing resection for diverticulitis?

BACKGROUND

By 2030, projections indicate that nearly half of USS adults will be obese, with 29 states exceeding a 50% obesity rate. High Body Mass Index (BMI) presents particular challenges in treating diverticulitis, including worsened symptoms and increased risk of surgical complications. The Robotic Natural orifice Intracorporeal Anastomosis with Transrectal Extraction (NICE) procedure has been developed for colorectal surgeries to tackle these challenges. This study evaluates the efficacy of the Robotic NICE procedure in achieving comparable surgical outcomes in patients with both high and normal BMI.

METHODS

This retrospective cohort study assessed the outcomes of robotic-assisted colectomy utilizing the NICE technique in patients with diverticulitis, dividing them into two groups based on BMI: high BMI (≥ 30 kg/m^2) and non-high BMI (< 30 kg/m^2).

RESULTS

Among the 194 patients analyzed, the incidence of complicated diverticulitis was significantly higher in the high BMI group (60.5%) compared to the non-high BMI group (39%; p = 0.003).The high BMI group had higher ASA scores, indicating sicker patients. The high BMI group also had a significantly higher rate of unplanned operations within 30 days (7.9% vs. 1.7%, p = 0.034). However, no significant differences were observed in the length of hospital stay, time to first flatus, or ICU admission rates between the two groups. Binary logistic regression highlighted the length of stay as a significant predictor of postoperative complications (Odds Ratio: 1.9686, 95% CI: 1.372-2.825, p < 0.001). Other factors, including age, operative time, and gender, did not significantly predict complications.

CONCLUSION

The findings suggest that the Robotic NICE procedure can mitigate some of the challenges typically associated with conventional minimally invasive surgery in which abdominal wall incision is made, providing consistent outcomes regardless of BMI. Further research is needed to explore long-term benefits, aiming to establish this approach as a standard for managing diverticulitis in our patient population.

Pathologic Outcomes and Survival in Patients with Rectal Cancer and Increased Body Mass Index

INTRODUCTION

We assessed the association between increased body mass index (BMI) and rectal cancer outcomes.

METHODS

We included patients who underwent surgery for stage I-III rectal adenocarcinoma who were divided according to BMI at diagnosis: ideal BMI (18.5-24.9 kg/m2) and increased BMI (≥25 kg/m2). Groups were compared using univariate association analyses relative to baseline characteristics, pathologic outcomes, overall survival (OS), and disease-free survival (DFS). Main outcome measures involved circumferential resection margin (CRM), pathologic TNM stage, total mesorectal incision (TME) grade, OS, and DFS.

RESULTS

243 patients (64.6% male; median age 59 years) with a median BMI of 26.3 kg/m2 were included. 62.1% had BMI ≥25 kg/m2. Increased BMI patients had similar proportions of males (66.9% vs. 60.9%; p = 0.407) and comorbidities (ASA III: 47% vs. 37.4%; p = 0.24) to ideal BMI patients. There were no significant differences in cN1-2 stage (p = 0.279) or positive CRM (p = 0.062) rates. The groups had similar complete/near-complete TME, pathologic TN stage, and survival rates. Pathologic and survival outcomes were also similar with a BMI cutoff of 30.

CONCLUSIONS

There was a trend toward more nodal involvement in preoperative assessment and less CRM involvement in the final pathology of patients with increased BMI. Complete/near-complete TME and survival rates were comparable between the groups.

Conversion rate to open surgery during transanal total mesorectal excision (TaTME) for rectal cancer: a single-center experience

Minimally invasive techniques for rectal cancer have demonstrated considerable advantages in terms of faster recovery and less post-operative complications. However, due to the complex anatomy and a limited surgical field, conversion to open surgery is still sometimes required, with a negative impact on the short-and long-term outcomes. The purpose of this study was to analyse the conversion rate to open abdominal surgery during laparoscopic transanal total mesorectal excision (TaTME) procedures performed at a high-volume Italian referral center. All consecutive TaTME performed for mid-to-low rectal cancer between 2015 and 2023 were reviewed, independently if treated with a primary anastomosis (with/without a diverting ostomy) or an end stoma. All procedures were performed using a standardized approach by the same surgical team. Patients with benign diagnosis that underwent different-from rectal resection procedures and cases pre-operatively scheduled for open surgery were excluded. The primary outcome of interest was the rate of conversion, defined as an un-planned intraoperative switch to open surgery using a midline laparotomy. Secondary aims included the comparison of patients who had a longer vs shorter operative time. Out of 220 patients, 210 were selected. In 187 cases, a primary anastomosis was performed, while 23 patients received a terminal colostomy (1 in the converted group; 22 in the full MIS- TaTME group, 10.6%). A surgical approach modification occurred in two cases, with a conversion rate of 0.95%. Median operative time was 281 min. Reasons for conversions included intra-operative difficulties impairing the mini-invasive procedure without intra-operative complications in one case, and difficulties in the laparoscopic control of an intraoperative bleeding due to a splenic lesion in another patient. Male sex and a higher BMI were found to be statistically significantly associated to longer operative time (respectively: p = 0.001 and p = 0.0025). In a high-volume center, a standardized TaTME is associated to a low conversion rate to open abdominal surgery.

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 ).

The impact of operative approach for obese colorectal cancer patients: analysis of the National Inpatient Sample 2015-2019

AIM

Obesity is a well-established risk factor for the development of colorectal cancer. As such, patients undergoing surgery for colorectal cancer have increasingly higher body mass indices (BMIs). The advances in minimally invasive surgical techniques in recent years have helped surgeons circumvent some of the challenges associated with operating in the setting of obesity. While previous studies suggest that laparoscopy improves outcomes compared with open surgery in obese patients, this has never been established at the population level. Therefore, we designed a retrospective database study using the National Inpatient Sample (NIS) with the aim of comparing laparoscopic with open approaches for obese patients undergoing surgery for colorectal cancer.

METHOD

A retrospective analysis of the NIS from 2015 to 2019 was conducted including patients with a BMI of greater than 30 kg/m2 undergoing surgery for colorectal cancer. The primary outcomes were postoperative in-hospital morbidity and mortality. Secondary outcomes included postoperative system-specific complications, total admission healthcare cost and length of stay (LOS). Multivariable logistic and linear regressions were utilized to compare the two operative approaches.

RESULTS

A total of 4742 patients underwent open surgery and 3231 underwent laparoscopic surgery. We observed a significant decrease in overall postoperative morbidity [17.5% vs. 31.4%, adjusted odds ratio (aOR) 0.56, 95% confidence interval (CI) 0.50-0.64; p < 0.001], gastrointestinal morbidity (8.1% vs. 14.5%, aOR 0.59, 95% CI 0.50-0.69; p < 0.001) and genitourinary morbidity (10.1% vs. 18.6%, aOR 0.61, 95% CI 0.52-0.70; p < 0.001) with the use of laparoscopy. Postoperative LOS was 1.7 days shorter (95% CI 1.5-2.0, p < 0.001) and cost of admission was decreased by $9106 (95% CI $4638-$13 573, p < 0.001) with laparoscopy.

CONCLUSION

Laparoscopic surgery for obese patients with colorectal cancer is associated with significantly decreased postoperative morbidity and improved healthcare resource utilization compared with open surgery. Laparoscopic approaches should be relied upon whenever feasible for these patients.

Effect of Body Mass Index on Outcomes of Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Objective

The current study aimed to assess the efficacy and safety of percutaneous nephrolithotomy (PCNL) in obese and overweight individuals based on body mass index (BMI).

Methods

We electronically explored the databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar databases for all types of comparative studies investigating the role of BMI on PCNL outcomes. Only studies defining obesity as >30 kg/m² were included. Efficacy outcomes were stone-free rates and operating time while safety outcomes were complications and length of hospital stay (LOS).

Results

Eighteen studies with 101,363 patients were included. We noted no difference in the stone-free rates after PCNL for morbid obese vs normal BMI patients (OR: 0.78 95% CI, 0.57, 1.08 I²= 7% p = 0.13), overweight vs normal (OR: 1.01 95% CI, 0.89, 1.15 I²= 1% p = 0.83) and obese vs normal patients (OR: 1.00 95% CI, 0.87, 1.16 I²= 0% p = 0.95). PCNL operative time was significantly increased in morbid obese (MD: 9.36 95% CI, 2.85, 15.88 I²= 76% p = 0.005) and obese patients as compared with normal patients (MD: 2.15 95% CI, 1.20, 3.10 I²= 0% p < 0.00001), but not for overweight patients. There was no difference in the odds of complications between morbid obese vs normal (OR: 1.26 95% CI, 0.93, 1.72 I²= 0% p = 0.13), overweight vs normal (OR: 1.11 95% CI, 0.96, 1.28 I²= 0% p = 0.15), and obese vs normal patients (OR: 1.07 95% CI, 0.91, 1.27 I²= 0% p = 0.40). LOS was significantly reduced in obese patients (MD: −0.12 95% CI, −0.20, −0.04 I²= 0% p = 0.004) as compared to normal patients, but not for morbid obese or overweight patients.

Conclusion

PCNL has similar efficacy and safety in morbidly obese, obese, and overweight patients as compared to normal BMI patients with no difference in the stone-free and complication rates. Evidence suggests that operating time is increased in morbidly obese and obese patients and the latter may have shorter LOS.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42022313599.