Endoscopic Surgical Skill Qualification System: propensity-score matched cohort analysis of accredited supervisors in laparoscopic rectal cancer surgery

Young pediatric surgeons without endoscopic surgical skill qualification safely perform advanced endoscopic surgery under the supervision of expert qualified surgeons

BACKGROUND

Young pediatric surgeons should receive adequate training in various minimally invasive surgeries (MIS). However, it is essential to maintain patient safety and outcomes during the learning process. In Japan, the endoscopic surgical skill qualification (ESSQ) system in pediatric surgery was initiated by the Japan Society for Endoscopic Surgery (JSES) in 2009 to objectively evaluate the skill of endoscopic surgeons. This study compared perioperative outcomes between pediatric surgeons with ESSQ qualifications and those without (non-ESSQ).

METHODS

We retrospectively reviewed the medical records of children with choledochal cyst (CC), lobectomy, and biliary atresia (BA) who underwent MIS at our hospital from 2013 to 2023. We assessed the performance of nonqualified surgeons assisted by supervisors with ESSQ qualifications.

RESULTS

This study included the records of 101 surgical cases with CC (operated by ESSQ: 36, non-ESSQ: 65), 78 patients with BA (operated by ESSQ: 35, non-ESSQ: 43), and 67 patients with lobectomy (operated by ESSQ: 31, non-ESSQ: 36). For the CC and lobectomy groups, there were no significant differences in operating time, blood loss, and postoperative complications (PO) between the ESSQ and non-ESSQ groups. In BA, the operative times for the ESSQ and non-ESSQ groups were 310 and 377 min, respectively (p = 0.001). Furthermore, no significant differences were observed in blood loss, PO, jaundice-clearance ratio, and jaundice-free survival rate with the native liver between the two groups.

CONCLUSION

The results indicate that young pediatric surgeons can safely perform MIS while practicing under the supervision of experienced ESSQ-qualified surgeons.

A multicentre prospective single-arm clinical trial to evaluate the treatment outcomes of prophylactic laparoscopic lateral pelvic lymph node dissection for advanced lower rectal cancer

AIM

There has been no prospective multicentre validation of the treatment outcomes of minimally invasive lateral pelvic lymph node dissection for lower rectal cancer; hence, this prospective study aimed to evaluate the treatment outcomes of prophylactic laparoscopic lateral pelvic lymph node dissection.

METHOD

Between May 2018 and August 2021, 90 patients with Stage II-III rectal cancer were registered. The clearance range for lateral pelvic lymph node dissection included the lymph nodes around the internal iliac artery and the obturator lymph nodes, while the autonomic nerves were generally preserved. The primary outcome was the incidence of Grade III-IV postoperative complications at discharge. The secondary outcomes were surgical and pathological outcomes, urinary function, sexual function, disease-free survival and overall survival. The experience of each facility and surgeon requirements were set to maintain quality control of lateral pelvic lymph node dissection.

RESULTS

Of the 90 patients, 87 were analysed after exclusion of ineligible patients. There were 30 and 57 cases, respectively, of Stage II and III rectal cancer, among which 17 patients underwent neoadjuvant chemotherapy. The median operating time and blood loss were 472 min and 55 mL, respectively. Postoperative complications were observed in 22 patients (25.3%), and the primary outcome of Grade III postoperative complication was observed in five patients (5.7%). Eight lateral lymph nodes were harvested bilaterally, and lateral lymph node metastasis was observed in 14 patients.

CONCLUSION

Prophylactic lateral pelvic lymph node dissection can be safely performed with adequately quality-controlled laparoscopic procedures.

Robotic versus laparoscopic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

OBJECTIVE

Robotic surgery is being increasingly used for colorectal cancer surgery. However, its utility versus laparoscopic surgery in older patients is unclear. We systematically examined evidence to assess the differences in short-term outcomes of robotic versus laparoscopic surgery for colorectal cancer in older patients.

MATERIAL AND METHODS

Comparative studies published on PubMed, Web of Science, Embase, and CENTRAL databases were searched up to August 30th, 2023.

RESULTS

Seven studies totaling 14,043 patients were included. Meta-analysis showed no difference in the operation time between the robotic and laparoscopic groups. Meta-analysis of ClavienDindo complications showed no difference between the robotic and laparoscopic groups for grades I and II or grades III and IV complications. Similarly, conversion to open surgery, reoperation rates and length of hospital stay were not significantly different between the two groups. Readmission rates and mortality rates were significantly lower with robotic surgery.

CONCLUSION

This first meta-analysis comparing outcomes of robotic and laparoscopic surgery in older colorectal cancer patients shows that both approaches result in no difference in operating time, complication rates, conversion to open surgery, reoperation rates, and LOS. Scarce data shows that mortality and readmission rates may be lower with robotic surgery.

Impact of Endoscopic Surgical Skill Qualification System-certified surgeons as operators in laparoscopic rectal cancer surgery in Japan: A propensity score-matched analysis (subanalysis of the EnSSURE study)

Background

In Japan, the Endoscopic Surgical Skill Qualification System (ESSQS) is used to evaluate surgical skills essential for laparoscopic surgery, but whether surgeons with this certification as operators improve the short-term outcomes and prognosis after rectal cancer surgery is unclear. This cohort study was designed to compare the short-term and long-term outcomes of laparoscopic surgery for advanced rectal cancer performed by an ESSQS-certified surgeon versus a surgeon without ESSQS certification.

Methods

The outcomes of cStage II and III rectal cancer surgery cases performed at 56 Japanese hospitals between 2014 and 2016 were retrospectively reviewed. To examine the impact of ESSQS-certified surgeons as surgeons, the outcomes of cases with only ESSQS-certified surgeons as operators were compared with those without involvement of ESSQS-certified surgeons.

Results

A total of 3197 cases were enrolled, with 1015 in which surgery was performed by ESSQS-certified surgeons, and 544 in which there was no involvement of ESSQS-certified surgeons. After propensity score matching, the ESSQS group had significantly shorter operative time (p < 0.001), a lower conversion rate to open surgery (p < 0.001), and more dissected lymph nodes (p = 0.002).

Conclusion

Laparoscopic rectal surgery performed by ESSQS-certified surgeons was significantly associated with improved short-term outcomes. This demonstrates the utility of the ESSQS certification system.

Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study

PURPOSE

Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons.

METHODS

This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience.

RESULTS

The study included 323 patients, subjected to a median operative time of 89 min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4 years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time.

CONCLUSION

Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

Advantages of robotic surgery for rectal cancer compared to laparoscopic surgery: pelvic anatomy and its impact on urinary dysfunction

The anatomical dimensions and the shape of the pelvis influence surgical difficulty for rectal cancer. Compared to conventional laparoscopic surgery, robot-assisted surgery is expected to improve surgical outcomes due to the multi-joint movement of its surgical instruments. The aim of this study was to investigate the impact of pelvic anatomical indicators on short-term outcomes of patients with rectal cancer. A retrospective analysis was conducted using data from 129 patients with rectal cancer who underwent conventional laparoscopic low anterior resection (L-LAR) or robot-assisted low anterior resection (R-LAR) with total mesorectal excision or tumor-specific mesorectal excision between January 2014 and December 2022. The transverse diameter of the lesser pelvis and the sacral promontory angle were used as indicators of pelvic anatomy. The sacral promontory angle was not associated with age and sex while the pelvic width was smaller in male than in female. The pelvic width did not affect postoperative complications in both L-LAR and R-LAR. In contrast, postoperative urinary dysfunction occurred more frequently in patients with a small sacral promontory angle (p = 0.005) in L-LAR although there was no impact on short-term outcomes in R-LAR. Multivariate analysis demonstrated that a small sacral promontory angle was an independent predictive factor for urinary dysfunction (p = 0.032). Sharp angulation of the sacral promontory was a risk factor for UD after L-LAR. Robot-assisted surgery could overcome anatomical difficulties and reduce the incidence of UD.

Minimally invasive versus open multivisceral resection for rectal cancer clinically invading adjacent organs: a propensity score-matched analysis

BACKGROUND

Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs.

PATIENTS AND METHODS

This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital.

RESULTS

Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively).

CONCLUSION

MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection.