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Hayden DM, Korous KM, Brooks E, Tuuhetaufa F, King-Mullins EM, Martin AM, Grimes C, Rogers CR. Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2023; 37:3306-3320. [PMID: 36520224 PMCID: PMC10947550 DOI: 10.1007/s00464-022-09793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.
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Affiliation(s)
- Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin M Korous
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA
| | - Ellen Brooks
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | - Fa Tuuhetaufa
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | | | - Abigail M Martin
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chassidy Grimes
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Charles R Rogers
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA.
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Clark CJ, Adler R, Xiang L, Shah SK, Cooper Z, Kim DH, Lin KJ, Hsu J, Lipsitz S, Weissman JS. Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study. Am J Surg 2023:S0002-9610(23)00108-3. [PMID: 37031040 DOI: 10.1016/j.amjsurg.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. METHODS Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. RESULTS 5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). CONCLUSIONS The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.
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Peritoneal metastases in elderly patients with colorectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2558-2564. [PMID: 35662530 DOI: 10.1016/j.ejso.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/15/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND With the introduction of cytoreductive surgery with intraperitoneal chemotherapy and the development of new systemic anti-cancer agents, the treatment of colorectal cancer (CRC) patients with peritoneal metastases has changed. Real-world data on the treatment of elderly patients and their clinical outcomes is lacking. METHODS All CRC patients diagnosed with synchronous peritoneal metastases (SPM) during 2008-2019 (n = 7,748) were identified from the Netherlands Cancer Registry. Trends in treatment and postoperative mortality were described by age category (<70, 70-74, 75-79, ≥80 years) and period of diagnosis (2008-2013, 2014-2019). Kaplan-Meier curves were constructed, and log-rank tests were performed to evaluate differences in overall survival (OS). RESULTS With increasing age, less patients received multimodality treatment and systemic treatment. Of the patients aged <70 years, 38% underwent multimodality treatment and 35% palliative systemic therapy, declining to 4% and 12% in patients ≥80 years. A large and increasing proportion of elderly patients did not receive cancer-directed treatment, this increased from 32% in 2008-2013 to 41% in 2014-2019 in 75-79 years old patients and from 52% to 65% in ≥80 years old. Postoperative mortality decreased in all age categories over time, OS remained stable. The median OS of elderly patients ranged from 8 months in 70-74 years old to 3 months in patients aged ≥80 years. DISCUSSION Age strongly affects treatment of patients with SPM, with a large and increasing proportion of elderly patients not receiving cancer-directed treatment. Their prognosis remains very poor. There is a need for therapeutic options that are well tolerable for elderly patients.
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Syvyk S, Roberts SE, Finn CB, Wirtalla C, Kelz R. Colorectal cancer disparities across the continuum of cancer care: A systematic review and meta-analysis. Am J Surg 2022; 224:323-331. [PMID: 35210062 DOI: 10.1016/j.amjsurg.2022.02.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/27/2022] [Accepted: 02/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Disparate colorectal cancer outcomes persist in vulnerable populations. We aimed to examine the distribution of research across the colorectal cancer care continuum, and to determine disparities in the utilization of Surgery among Black patients. METHODS A systematic review and meta-analysis of colorectal cancer disparities studies was performed. The meta-analysis assessed three utilization measures in Surgery. RESULTS Of 1,199 publications, 60% focused on Prevention, Screening, or Diagnosis, 20% on Survivorship, 15% on Treatment, and 1% on End-of-Life Care. A total of 16 studies, including 1,110,674 patients, were applied to three meta-analyses regarding utilization of Surgery. Black patients were less likely to receive surgery, twice as likely to refuse surgery, and less likely to receive laparoscopic surgery, when compared to White patients. CONCLUSIONS Since 2011, the majority of research focused on prevention, screening, or diagnosis. Given the observed treatment disparities among Black patients, future efforts to reduce colorectal cancer disparities should include interventions within Surgery.
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Affiliation(s)
- Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia PA, USA
| | - Sanford E Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia PA, USA; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caitlin B Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia PA, USA; NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Surgery, New York, NY, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia PA, USA; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia PA, USA; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Hua Q, Xu W, Shen X, Tian X, Zhang H, Li Y, Xu P. Dynamic changes of plasma extracellular vesicle long RNAs during perioperative period of colorectal cancer. Bioengineered 2021; 12:3699-3710. [PMID: 34266354 PMCID: PMC8806447 DOI: 10.1080/21655979.2021.1943281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Extracellular vesicles (EVs) long RNAs (exLRs) have been shown to be indicators for the diagnosis and prognosis of colorectal cancer (CRC); however, the dynamic changes of exLRs during perioperative period and their cellular sources in CRC remains largely unknown. In this study, exLR sequencing (exLR-seq) was performed on plasma samples from three CRC patients at four time points (before surgery [T0], after extubation [T1], 1 day after surgery [T2], and 3 days after surgery [T3]). Bioinformatics approaches were used to investigate the profile and biofunctions of exLRs and their cellular sources. Greater than 12,000 mRNAs and 2,000 lncRNAs were reliably detected in each exLR-seq sample. Compared with T0, there were 110 differentially expressed genes (DEGs) in T1, 60 DEGs in T2, and 50 DEGs in T3. A total of 11 DEGs were found at all three time points and were related to membrane potential. In addition, compared to T0, 22 differentially expressed lncRNAs (DELRs) were found in T1, 19 DELRs in T2, and 38 DELRs in T3. Moreover, only three DELRs were detected at all three time points. Interestingly, EVs from CD8 + T cells, CD4+ memory T cells and NK cells decreased after surgery and the absolute quantity of EVs from immune cells were reduced as well. In summary, this study was the first to characterize the dynamic changes of exLRs during perioperative period and the cellular sources. These findings established the foundation for further studies involving the effects of these dynamically changed exLRs on CRC.
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Affiliation(s)
- Qing Hua
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhao Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xuefang Shen
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xi Tian
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Hailiang Zhang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yan Li
- Fudan University, Shanghai Cancer Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Pingbo Xu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Mini fluid chAllenge aNd End-expiratory occlusion test to assess flUid responsiVEness in the opeRating room (MANEUVER study): A multicentre cohort study. Eur J Anaesthesiol 2021; 38:422-431. [PMID: 33399372 DOI: 10.1097/eja.0000000000001406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The fluid challenge response in surgical patients can be predicted by functional haemodynamic tests. Two tests, the mini-fluid challenge (mini-FC) and end-expiratory occlusion test (EEOT), have been assessed in a few small single-centre studies with conflicting results. In general, functional haemodynamic tests have not performed reliably in predicting fluid responsiveness in patients undergoing laparotomy. OBJECTIVE This trial is designed to address and compare the reliability of the EEOT and the mini-FC in predicting fluid responsiveness during laparotomy. DESIGN Prospective, multicentre study. SETTING Three university hospitals in Italy. PATIENTS A total of 103 adults patients scheduled for elective laparotomy with invasive arterial monitoring. INTERVENTIONS The study protocol evaluated the changes in the stroke volume index (SVI) 20 s (EEOT20) and 30 s (EEOT30) after an expiratory hold and after a mini-FC of 100 ml over 1 min. Fluid responsiveness required an increase in SVI at least 10% following 4 ml kg-1 of Ringer's solution fluid challenge infused over 10 min. MAIN OUTCOME MEASUREMENTS Haemodynamic data, including SVI, were obtained from pulse contour analysis. The area under the receiver operating characteristic curves of the tests were compared with assess fluid responsiveness. RESULTS Fluid challenge administration induced an increase in SVI at least 10% in 51.5% of patients. The rate of fluid responsiveness was comparable among the three participant centres (P = 0.10). The area under the receiver operating characteristic curves (95% CI) of the changes in SVI after mini-FC was 0.95 (0.88 to 0.98), sensitivity 98.0% (89.5 to 99.6) and specificity 86.8% (75.1 to 93.4) for a cut-off value of 4% of increase in SVI. This was higher than the SVI changes after EEOT20, 0.67 (0.57 to 0.76) and after EEOT30, 0.73 (0.63 to 0.81). CONCLUSION In patients undergoing laparotomy the mini-FC reliably predicted fluid responsiveness with high-sensitivity and specificity. The EEOT showed poor discriminative value and cannot be recommended for assessment of fluid responsiveness in this surgical setting. TRIAL REGISTRATION NCT03808753.
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Hospital robotic use for colorectal cancer care. J Robot Surg 2020; 15:561-569. [PMID: 32876922 DOI: 10.1007/s11701-020-01142-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.
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Lo BD, Zhang GQ, Stem M, Sahyoun R, Efron JE, Safar B, Atallah C. Do specific operative approaches and insurance status impact timely access to colorectal cancer care? Surg Endosc 2020; 35:3774-3786. [PMID: 32813058 DOI: 10.1007/s00464-020-07870-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/05/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The increased use of minimally invasive surgery in the management of colorectal cancer has led to a renewed focus on how certain factors, such as insurance status, impact the equitable distribution of both laparoscopic and robotic surgery. Our goal was to analyze surgical wait times between robotic, laparoscopic, and open approaches, and to determine whether insurance status impacts timely access to treatment. METHODS After IRB approval, adult patients from the National Cancer Database with a diagnosis of colorectal cancer were identified (2010-2016). Patients who underwent radiation therapy, neoadjuvant chemotherapy, had wait times of 0 days from diagnosis to surgery, or had metastatic disease were excluded. Primary outcomes were days from cancer diagnosis to surgery and days from surgery to adjuvant chemotherapy. Multivariable Poisson regression analysis was performed. RESULTS Among 324,784 patients, 5.9% underwent robotic, 47.5% laparoscopic, and 46.7% open surgery. Patients undergoing robotic surgery incurred the longest wait times from diagnosis to surgery (29.5 days [robotic] vs. 21.7 [laparoscopic] vs. 17.2 [open], p < 0.001), but the shortest wait times from surgery to adjuvant chemotherapy (48.9 days [robotic] vs. 49.9 [laparoscopic] vs. 54.8 [open], p < 0.001). On adjusted analysis, robotic surgery was associated with a 1.46 × longer wait time to surgery (IRR 1.462, 95% CI 1.458-1.467, p < 0.001), but decreased wait time to adjuvant chemotherapy (IRR 0.909, 95% CI 0.905-0.913, p < 0.001) compared to an open approach. Private insurance was associated with decreased wait times to surgery (IRR 0.966, 95% CI 0.962-0.969, p < 0.001) and adjuvant chemotherapy (IRR 0.862, 95% CI 0.858-0.865, p < 0.001) compared to Medicaid. CONCLUSION Though patients undergoing robotic surgery experienced delays from diagnosis to surgery, they tended to initiate adjuvant chemotherapy sooner compared to those undergoing open or laparoscopic approaches. Private insurance was independently associated not only with access to robotic surgery, but also shorter wait times during all stages of treatment.
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Affiliation(s)
- Brian D Lo
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - George Q Zhang
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Rebecca Sahyoun
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Division of Colon and Rectal Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Blalock 618, Baltimore, MD, 21205, USA.
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Chen SY, Stem M, Gearhart SL, Safar B, Fang SH, Azad NS, Murphy AG, Narang AK, Wolfgang CL, Efron JE. Readmission Adversely Affects Survival in Surgical Rectal Cancer Patients. World J Surg 2019; 43:2506-2517. [PMID: 31222644 DOI: 10.1007/s00268-019-05053-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Readmission has received attention as a potential healthcare quality metric. No studies have investigated the relationship between readmission and survival in patients undergoing rectal cancer surgery. The aims of this study were to identify factors associated with 30-day readmission after rectal cancer surgery and to determine the impact of readmission on overall survival (OS). METHODS Patients who underwent surgical treatment for rectal/rectosigmoid adenocarcinoma stages I-IV were identified using the National Cancer Database (2004-2014). Multivariable logistic regression was used to identify factors for readmission. 2:1 nearest neighbor caliper matching without replacement was used to ensure similarity of patients being compared. Survival analyses were performed using Kaplan-Meier method along with log-rank test and Cox proportional hazards model. RESULTS Of 110,167 patients, 7045 (6.39%) were readmitted. Factors associated with readmission included higher Charlson comorbidity score, non-private or no insurance, procedure type, hospitals in the Northeast, South, and Midwest regions, and prolonged length of stay. Within the matched cohort (13,756 non-readmitted and 6878 readmitted), readmitted patients had worse 5- and 10-year OS regardless of cancer stage (p < 0.001) and procedure type. Five- and 10-year OS were 58.98% and 41.01% for readmitted patients, 64.96% and 43.50% for non-readmitted patients. Readmitted patients had shorter OS by 13.14 months and increased risk of mortality (HR 1.20, 95% CI 1.15-1.25, p < 0.001). CONCLUSIONS Thirty-day readmission after rectal cancer surgery is associated with decreased OS. Efforts to reduce readmissions should be considered to advance cancer care and enhance the potential for improved patient survival.
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Affiliation(s)
- Sophia Y Chen
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandy H Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nilofer S Azad
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian G Murphy
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Mark M. Ravitch Professor of Surgery, The Johns Hopkins University School of Medicine, 733 North Broadway, Suite G-45, Baltimore, MD, 21205, USA.
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Ng KT, Tsia AKV, Chong VYL. Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. World J Surg 2019; 43:1146-1161. [PMID: 30610272 DOI: 10.1007/s00268-018-04896-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). METHODS All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. RESULTS Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I2 = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I2 = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I2 = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). CONCLUSIONS This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
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Affiliation(s)
- Ka Ting Ng
- Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Malaysia.
| | - Azlan Kok Vui Tsia
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| | - Vanessa Yu Ling Chong
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
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Batool F, Collins SD, Albright J, Ferraro J, Wu J, Krapohl GL, Campbell DA, Cleary RK. A Regional and National Database Comparison of Colorectal Outcomes. JSLS 2019; 22:JSLS.2018.00031. [PMID: 30410300 PMCID: PMC6203949 DOI: 10.4293/jsls.2018.00031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background and Objectives: The traditional open approach is still a common option for colectomy and the most common option chosen for rectal resections for cancer. Randomized trials and large database studies have reported the merits of the minimally invasive approach, while studies comparing laparoscopic and robotic options have reported inconsistent results. Methods: This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in protocol-driven regional and national databases. Logistic and multiple linear regression analyses were used to compare standard 30-day colorectal outcomes in the Michigan Surgical Quality Collaborative (MSQC) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases. The primary outcome was overall complications. Results: A total of 10,054 MSQC patients (open 37.5%, laparoscopic 48.8%, and robotic 13.6%) and 80,535 ACS-NSQIP patients (open 25.0%, laparoscopic 67.1%, and robotic 7.9%) met inclusion criteria. Overall complications and surgical site infections were significantly favorable for the laparoscopic and robotic approaches compared with the open approach. Anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach in ACS-NSQIP, while there was no significant difference between robotic and open approaches in MSQC. Laparoscopic complications were significantly less than robotic complications in MSQC but significantly more in ACS-NSQIP. Laparoscopic 30-day mortality was significantly less than for the robotic approach in MSQC, but there was no difference in ACS-NSQIP. Conclusion: Minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. Individual complication comparisons vary between databases, and caution should be exercised when interpreting results in context.
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Affiliation(s)
- Farwa Batool
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA
| | - Jeremy Albright
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Jane Ferraro
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Juan Wu
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Greta L Krapohl
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA
| | - Darrell A Campbell
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
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Al-Mazrou AM, Baser O, Kiran RP. Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection. J Gastrointest Surg 2018; 22:1043-1051. [PMID: 29404985 DOI: 10.1007/s11605-018-3699-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 01/18/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time. METHODS From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years. RESULTS Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402). CONCLUSION Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA.
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
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13
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Holmer C, Kreis ME. Systematic review of robotic low anterior resection for rectal cancer. Surg Endosc 2017; 32:569-581. [DOI: 10.1007/s00464-017-5978-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/05/2017] [Indexed: 01/30/2023]
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14
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Ho VP, Steinhagen E, Angell K, Navale SM, Schiltz NK, Reimer AP, Madigan EA, Koroukian SM. Psychiatric disease in surgically treated colorectal cancer patients. J Surg Res 2017; 223:8-15. [PMID: 29433889 DOI: 10.1016/j.jss.2017.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/30/2017] [Accepted: 06/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Underlying psychiatric conditions may affect outcomes of surgical treatment for colorectal cancer (CRC) because of complex clinical presentation and treatment considerations. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal surgery performed in the presence of obstruction, perforation, and/or peritonitis (OPP-surgery). MATERIALS AND METHODS Using data from the 2007-2011 National Inpatient Sample, we identified patients with a diagnosis of CRC undergoing colorectal surgery. In addition to somatic comorbid conditions flagged in the National Inpatient Sample, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions. Our study outcome was OPP-surgery. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-surgery, after adjusting for patient demographics and somatic comorbidities. RESULTS Our study population included 591,561 patients with CRC and undergoing colorectal cancer surgery, of whom 60.6% were aged 65 years or older, 49.4% were women, and 6.3% had five or more comorbid conditions. Then, 17.9% presented with PSYCH. The percent of patients undergoing OPP-surgery was 13.9% in the study population but was significantly higher for patients with schizophrenia (19.3%), delirium and dementia (18.5%), developmental disorders (19.7%), and alcohol/substance abuse (19.5%). In multivariable analysis, schizophrenia, delirium/dementia, and alcohol/substance abuse were each independently associated with increased rates of OPP-surgery. CONCLUSIONS Patients with PSYCH may have obstacles in receiving optimal care for CRC. Those with PSYCH diagnoses had significantly higher rates of OPP-surgery. Additional evaluation is required to further characterize the clinical implications of advanced disease presentation for patients with PSYCH diagnoses and colorectal cancer.
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Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Emily Steinhagen
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kelsey Angell
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Suparna M Navale
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas K Schiltz
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Andrew P Reimer
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; Critical Care Transport, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth A Madigan
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
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15
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Growth in robotic-assisted procedures is from conversion of laparoscopic procedures and not from open surgeons’ conversion: a study of trends and costs. Surg Endosc 2017; 32:2106-2113. [DOI: 10.1007/s00464-017-5908-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 10/03/2017] [Indexed: 11/26/2022]
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16
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Gani F, Cerullo M, Zhang X, Canner JK, Conca-Cheng A, Hartzman AE, Husain SG, Cirocco WC, Traugott AL, Arnold MW, Johnston FM, Pawlik TM. Effect of surgeon “experience” with laparoscopy on postoperative outcomes after colorectal surgery. Surgery 2017; 162:880-890. [DOI: 10.1016/j.surg.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/23/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022]
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17
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de Andrade Calaça PR, Bezerra RP, Albuquerque WWC, Porto ALF, Cavalcanti MTH. Probiotics as a preventive strategy for surgical infection in colorectal cancer patients: a systematic review and meta-analysis of randomized trials. Transl Gastroenterol Hepatol 2017; 2:67. [PMID: 28905008 DOI: 10.21037/tgh.2017.08.01] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infection following abdominal surgery remains a major factor in morbidity among colorectal cancer (CRC) patients. Probiotic therapy has been suggested to improve the clinical and laboratory outcome of patients undergoing gastrointestinal surgery. The aim of this study was to investigate the efficacy of probiotic lactic acid bacteria in patients with CRC in the pre- and postoperative phases. METHODS Systematic database searches identified 1,080 related articles. However, only seven articles were selected according to the eligibility criteria for qualitative and quantitative evaluation. RESULTS Most of the reviewed articles presented satisfactory results related to the prevention of surgical inflammation in patients undergoing resection of CRC when using strains of Lactobacillus genus, predominantly. CONCLUSIONS Probiotics are suggested to prevent surgical inflammation of CRC, at the same time that the combination of particular microorganisms administered is beneficial to the treatment and surgical recovery.
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Affiliation(s)
- Priscilla Régia de Andrade Calaça
- Laboratory of Technology of Bioactive Product (LABTECBIO), Department of Morphology and Animal Physiology, DMFA, Federal Rural University of Pernambuco, Recife, Brazil.,Research Support Center (CENAPESQ), Federal Rural University of Pernambuco, Recife, Brazil
| | - Raquel Pedrosa Bezerra
- Laboratory of Technology of Bioactive Product (LABTECBIO), Department of Morphology and Animal Physiology, DMFA, Federal Rural University of Pernambuco, Recife, Brazil.,Research Support Center (CENAPESQ), Federal Rural University of Pernambuco, Recife, Brazil
| | - Wendell Wagner Campos Albuquerque
- Laboratory of Technology of Bioactive Product (LABTECBIO), Department of Morphology and Animal Physiology, DMFA, Federal Rural University of Pernambuco, Recife, Brazil
| | - Ana Lúcia Figueiredo Porto
- Laboratory of Technology of Bioactive Product (LABTECBIO), Department of Morphology and Animal Physiology, DMFA, Federal Rural University of Pernambuco, Recife, Brazil.,Research Support Center (CENAPESQ), Federal Rural University of Pernambuco, Recife, Brazil.,Laboratory of Immunopathology Keizo Asami (LIKA), Federal University of Pernambuco (UFPE), Recife, Brazil
| | - Maria Taciana Holanda Cavalcanti
- Laboratory of Technology of Bioactive Product (LABTECBIO), Department of Morphology and Animal Physiology, DMFA, Federal Rural University of Pernambuco, Recife, Brazil.,Research Support Center (CENAPESQ), Federal Rural University of Pernambuco, Recife, Brazil
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18
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Gani F, Cerullo M, Canner JK, Conca-Cheng A, Harzman AE, Husain SG, Cirocco WC, Arnold MW, Traugott A, Johnston FM, Pawlik TM. Defining payments associated with the treatment of colorectal cancer. J Surg Res 2017; 220:284-292. [PMID: 29180193 DOI: 10.1016/j.jss.2017.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND While bundled payments aim to reduce variations in health care spending across the continuum of care, data reporting on variations in payments for privately insured patients undergoing treatment for colon cancer (CC) are lacking. The current study sought to characterize variations in payments received for the treatment of CC using a cohort of commercially insured patients. METHODS Patients who underwent a colectomy for CC were identified using the MarketScan Database for 2010-2014. Multivariable regression analysis was used to calculate and compare risk-adjusted payments between patients. RESULTS A total of 18,337 patients were identified who met inclusion criteria. The median risk-adjusted payment for surgery was $26,408 (IQR: $19,193-$38,037) ranging from $19,762 (IQR: $15,595-$25,636) among patients in the lowest quartile of payments to $33,809 (IQR: $24,783-$48,254) for patients in the highest (+△71.1%). The median risk-adjusted payment for chemotherapy was $70,090 (IQR: $57,813-$83,216); compared with patients in the lowest quartile of payments, payments associated with chemotherapy were 40.4% higher among patients in the highest quartile of payments (Q1 versus Q4: $56,827 [IQR: 49,173-65,353] versus $79,801 [IQR: 67,270-90,999]). When stratified by treatment type, patients in the highest two quartiles of risk-adjusted payments accounted for a total of 58.5% of all payments, whereas patients in the lower two quartiles of risk-adjusted payments accounted for only 41.5% of all payments. A younger patient age, increasing patient comorbidity and undergoing an open operation were associated with higher overall payments. CONCLUSIONS Wide variations in payments exist for the treatment for colon cancer. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CC.
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Affiliation(s)
- Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alison Conca-Cheng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan E Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Syed G Husain
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - William C Cirocco
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mark W Arnold
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Amber Traugott
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Bilgin IA, Aytac E, Erenler I, Baca B, Hamzaoglu I, Karahasanoglu T. Combined laparoscopic-robotic approach in complex re-operative colorectal surgery - a video vignette. Colorectal Dis 2017; 19:598-599. [PMID: 28419688 DOI: 10.1111/codi.13687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
Affiliation(s)
- I A Bilgin
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - E Aytac
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - I Erenler
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - B Baca
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - I Hamzaoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
| | - T Karahasanoglu
- Department of General Surgery, Acibadem University School of Medicine, Istanbul, Turkey
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