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Panteleimonitis S, Miskovic D, Bissett-Amess R, Figueiredo N, Turina M, Spinoglio G, Heald RJ, Parvaiz A. Short-term clinical outcomes of a European training programme for robotic colorectal surgery. Surg Endosc 2020; 35:6796-6806. [PMID: 33289055 PMCID: PMC8599412 DOI: 10.1007/s00464-020-08184-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery-EARCS). METHODS Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors. RESULTS Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups. CONCLUSIONS Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.
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Affiliation(s)
- Sofoklis Panteleimonitis
- School of Health and Care Professions, University of Portsmouth, St Andrews Court, St Michael's Road, Portsmouth, PO1 2PR, UK
| | | | | | - Nuno Figueiredo
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | - Matthias Turina
- Division of Colorectal Surgery and Proctology, University of Zurich Hospital, Moussonstrasse 2, 8044, Zurich, Switzerland
| | | | - Richard J Heald
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal.,Pelican Cancer Foundation, Dinwoodie Dr, Basingstoke, RG24 9NN, UK
| | - Amjad Parvaiz
- School of Health and Care Professions, University of Portsmouth, St Andrews Court, St Michael's Road, Portsmouth, PO1 2PR, UK. .,Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal. .,Poole Hospital NHS Trust, Longfleet road, Poole, BH15 2JB, UK.
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Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer. Int J Colorectal Dis 2019; 34:2101-2109. [PMID: 31713715 DOI: 10.1007/s00384-019-03431-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to assess the effects of socioeconomic deprivation on short-term outcomes and long-term overall survival following major resection of colorectal cancer (CRC) at a tertiary hospital in England. METHOD This was an observational cohort study of patients undergoing resection for colorectal cancer from January 2010 to December 2017. Deprivation was classified into quintiles using the English Indices of Multiple Deprivation 2010. Primary outcome was overall complications (Clavien-Dindo grades 1 to 5). Secondary outcomes were the major complications (Clavien-Dindo 3 to 5), length of hospital stay and overall survival. Outcomes were compared between most affluent group and most deprived group. Multivariate regression models were used to establish the relationship taking into account confounding variables. RESULTS One thousand eight hundred thirty-five patients were included. Overall and major complication rates were 44.9% and 11.5% respectively in the most affluent, and 54.6% and 15.6% in the most deprived group. Most deprived group was associated with higher overall complications (odds ratio 1.48, 95% CI 1.13-1.95, p = 0.005), higher major complications (odds ratio 1.49, 1.01-2.23, p = 0.048) and longer hospital stay (adjusted ratio 1.15, 1.06-1.25, p < 0.001) when compared with most affluent group. Median follow period was 41 months (interquartile range 20-64.5). Most deprived group had poor overall survival compared with most affluent, but it was not significant at the 5% level (hazard ratio 1.27, 0.99-1.62, p = 0.055). CONCLUSION Deprivation was associated with higher postoperative complications and longer hospital stay following major resection for CRC. Its relationship with survival was not statistically significant.
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Formisano G, Esposito S, Coratti F, Giuliani G, Salaj A, Bianchi PP. Structured training program in colorectal surgery: the robotic surgeon as a new paradigm. MINERVA CHIR 2018; 74:170-175. [PMID: 30484601 DOI: 10.23736/s0026-4733.18.07951-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND One major issue in general surgery is how to provide novice surgeons with a structured training program (STP). The aim of our study was to assess the efficacy of a STP in robotic colorectal surgery for young surgeons without prior experience in both open and laparoscopic colorectal surgery, who were autonomous in basic minimally-invasive surgical procedures. Right colectomy with intracorporeal anastomosis has been chosen as a model. METHODS Between May 2015 and December 2017 two junior attending surgeons were trained through a STP. Right colectomy was divided into three main learning modules (colonic mobilization, vascular control, intracorporeal anastomosis) and each one was carried out by the trainees for at least two times under direct supervision of the senior surgeon. After the initial robotic cases completely performed under formal proctoring, they were privileged to perform robotic right colectomy independently without a mentor (20 procedures). Operative time, conversion rate, intra- and postoperative complications, length of stay and pathological outcomes were the variables analyzed to assess the effectiveness of the STP. RESULTS The mean operative time was 200 minutes and no conversion was required. Neither intraoperative nor major postoperative complications were recorded and the mean length of hospital stay was 6 days. Mean nodal yield was 21. CONCLUSIONS A STP in robotic colorectal surgery is feasible and effective. Right colectomy represents a good model as first step of the program in order to develop multiple technical skills. Previous experience in open or laparoscopic colorectal surgery may not be necessary.
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Affiliation(s)
- Giampaolo Formisano
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy -
| | - Sofia Esposito
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Francesco Coratti
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Giuseppe Giuliani
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Adelona Salaj
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Paolo P Bianchi
- Department of General and Minimally-Invasive Surgery, Misericordia Hospital, Grosseto, Italy
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Gaitanidis A, Simopoulos C, Pitiakoudis M. What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature. Tech Coloproctol 2018; 22:151-160. [PMID: 29512045 DOI: 10.1007/s10151-018-1760-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 12/03/2017] [Indexed: 12/27/2022]
Abstract
Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.
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Affiliation(s)
- A Gaitanidis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece.
| | - C Simopoulos
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
| | - M Pitiakoudis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
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Miyata H, Mori M, Kokudo N, Gotoh M, Konno H, Wakabayashi G, Matsubara H, Watanabe T, Ono M, Hashimoto H, Yamamoto H, Kumamaru H, Kohsaka S, Iwanaka T. Association between institutional procedural preference and in-hospital outcomes in laparoscopic surgeries; Insights from a retrospective cohort analysis of a nationwide surgical database in Japan. PLoS One 2018; 13:e0193186. [PMID: 29505561 PMCID: PMC5837082 DOI: 10.1371/journal.pone.0193186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 02/06/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the use of laparoscopic surgeries (LS) and the association between its performance and hospitals' preference for LS over open surgeries. SUMMARY BACKGROUND DATA LS is increasingly used in many abdominal surgeries, albeit both with and without solid guideline recommendations. To date, the hospitals' preference (LS vs. open surgeries) and its association with in-hospital outcomes has not been evaluated. METHODS We enrolled patients undergoing 8 types of gastrointestinal surgeries in 2011-2013 in the Japanese National Clinical Database. We assessed the use of LS and the occurrences of surgery-related morbidity and mortality during the study period. Further, for 4 typical LS procedures, we assessed the hospitals' preference for LS by modeling the propensity to perform LS (over open surgeries) from patient-level factors, and estimating each institution's observed/expected (O/E) ratio for LS use. Institutions with O/E>2 were defined as LS-dominant. Using hierarchical logistic regression models, we assessed the association between LS preference and in-hospital outcomes. RESULTS Among 1,377,118 patients undergoing gastrointestinal procedures in 2,336 participating hospitals, use of LS increased in all 8 procedures (35.1% to 44.7% for distal gastrectomy (DG), and 27.5% to 43.2% for right hemi colectomy (RHC)). Those operated at LS-dominant hospitals were at an increased risk of operative death (OR 1.83 [95%CI, 1.37-2.45] for DG, 1.79 [95%CI, 1.43-2.25] for RHC) compared to standard O/E level hospitals (0.5≤O/E<2.0). CONCLUSIONS LS use widely increased during 2011-2013 in Japan. Facilities with higher than expected LS use had higher mortality compared to other hospitals, suggesting a need for careful patient selection and dissemination of the procedure.
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Affiliation(s)
- Hiroaki Miyata
- National Clinical Database, Tokyo, Japan
- Department of Health Policy and Management, Keio University, Tokyo, Japan
| | - Masaki Mori
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
- Japan Surgical Society, Tokyo, Japan
| | - Norihiro Kokudo
- Japan Surgical Society, Tokyo, Japan
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsukazu Gotoh
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
- Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Konno
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
- Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Go Wakabayashi
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Hisahiro Matsubara
- Japan Surgical Society, Tokyo, Japan
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toshiaki Watanabe
- Japan Surgical Society, Tokyo, Japan
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- National Clinical Database, Tokyo, Japan
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Hideki Hashimoto
- National Clinical Database, Tokyo, Japan
- Department of Health and Social Behavior, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Yamamoto
- National Clinical Database, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiraku Kumamaru
- National Clinical Database, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shun Kohsaka
- National Clinical Database, Tokyo, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Iwanaka
- National Clinical Database, Tokyo, Japan
- Bureau of Saitama Prefectural Hospitals, Saitama, Japan
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Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection. World J Surg 2018; 41:1896-1902. [PMID: 28255631 DOI: 10.1007/s00268-017-3925-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic colorectal surgery has a long learning curve. Using a modular-based training programme may shorten this. Concerns with laparoscopic surgery have been oncological compromise and poor surgical outcomes when training more junior surgeons. This study aimed to compare operative and oncological outcomes between trainees undergoing a mentored training programme and a consultant trainer. METHODS A prospective study of all elective laparoscopic colorectal resections was undertaken in a single institution. Operative and oncological outcomes were recorded. All trainees were mentored by a National Laparoscopic Trainer (Lapco), and results between trainer and trainees compared. RESULTS Three hundred cases were included, with 198 (66%) performed for cancer. The trainer undertook 199 (66%) of operations, whilst trainees performed 101 (34%). Anterior resection was the commonest operation (n = 124, 41%). There were no differences between trainer and trainees for the majority of surgical outcomes, including blood loss (p = 0.598), conversion to open (p = 0.113), anastomotic leak (p = 0.263), readmission (p = 1.000) and death rates (p = 0.549). Only length of stay (p = 0.034), stoma formation (p < 0.01) and operative duration (p = 0.007) were higher in the trainer cohort, reflecting the more complex cases undertaken. Overall, there were no significant differences in both short- and longer-term oncology outcomes according to the grade of operating surgeon, including lymph nodes in specimen, circumferential resection margin and 1- and 2-year radiological recurrence. CONCLUSION When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.
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Cheong JY, Young CJ. Hand-Assisted Laparoscopic Surgery: A Versatile Tool for Colorectal Surgeons. Ann Coloproctol 2017; 33:125-129. [PMID: 28932720 PMCID: PMC5603340 DOI: 10.3393/ac.2017.33.4.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/13/2017] [Indexed: 10/30/2022] Open
Abstract
PURPOSE Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical technique with the combined benefits of laparoscopic surgery while allowing the use of the surgeon's hand for better tactile control. Obesity has been associated with higher conversion rates with multiport laparoscopic surgery, but not with HALS. This study aimed to examine the versatility of HALS in various clinical contexts. METHODS All HALSs performed at 2 major tertiary centers in Sydney were prospectively collected for retrospective analysis. Variables including age, sex, body mass index (BMI), previous surgeries, pathologies including size and T-stage, and the number of conversions to a midline laparotomy were examined. RESULTS A total of 121 HALS colorectal resections were analyzed. The median age of the patients was 62 years, with 63.6% being women. Seven patients required conversion to a midline laparotomy. Of the 121 patients, 50.2% were overweight or obese, and 52.9% had undergone previous abdominal/pelvic operations. However, neither obesity nor abdominal adhesions from previous operations were an indication for conversion to an open laparotomy in any of the 7 converted patients. The presence of intra-abdominal adhesions did not impact the operative time. HALS allowed access to the entire colon and rectum and allowed resection of the bladder, uterus, and ureter, when these organs were involved. CONCLUSION HALS is a versatile, minimally invasive technique, which is independent of the patient's BMI, for performing a colorectal resection.
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Affiliation(s)
- Ju Yong Cheong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, and University of Sydney, Discipline of Surgery, Sydney, NSW, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, and University of Sydney, Discipline of Surgery, Sydney, NSW, Australia
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Cerdán Santacruz C, Frasson M, Flor-Lorente B, Ramos Rodríguez JL, Trallero Anoro M, Millán Scheiding M, Maseda Díaz O, Dujovne Lindenbaum P, Monzón Abad A, García-Granero Ximenez E. Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study. Surg Endosc 2017; 31:5032-5042. [PMID: 28455773 DOI: 10.1007/s00464-017-5548-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. METHODS This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. RESULTS 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p = 0.015), morbidity (p < 0.0001), wound infection (p < 0.0001), and post-operative length of stay (p < 0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p = 0.004), wound infection (OR 0.6; p < 0.0001), and length of post-operative stay (Effect-2 days; p < 0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). CONCLUSIONS In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.
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Affiliation(s)
- Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | - Marta Trallero Anoro
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
| | | | | | | | | | - Eduardo García-Granero Ximenez
- Department of General Surgery, Digestive Surgery Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain
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Hong ZL, Chen QY, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Lu J, Cao LL, Lin M, Tu RH, Huang CM. A preoperative scoring system to predict the risk of No.10 lymph node metastasis for advanced upper gastric cancer: a large case report based on a single-center study. Oncotarget 2017; 8:80050-80060. [PMID: 29108387 PMCID: PMC5668120 DOI: 10.18632/oncotarget.17273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/29/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose To investigate upper stomach carcinoma risk factors for No. 10 lymph node (LN) metastasis, and establish a preoperative scoring system to predict No.10 LN metastasis. Method Between January 2011 and December 2014, we prospectively collected and retrospectively analyzed the data of 398 patients with upper-third gastric cancer (GC) who underwent laparoscopic spleen-preserving hilar lymph-node dissection (SHLND). We use the logistics regression analysis risk factors of No. 10 LN metastasis to establish and verify a scoring model. Result Among the 398 patients examined, 38 patients had No. 10 LN metastasis, yielding a 9.6% transfer rate. The preoperative risk factor analysis for No. 10 LN metastasis in the modeling group showed that tumor size, preoperative T staging, and preoperative N staging are independent risk factors. To establish a scoring system, we divided the modeling group of patients into three levels: low risk, intermediate risk, and high risk. The No. 10 LN metastasis rates of the low risk, intermediate risk and high risk groups were 2.84%, 13.9% and 34.9% respectively, with statistically significant (P < 0.001). The value for the area under the ROC curve of the scoring system was 0.820, and there were no statistically significant differences between the observed and predicted incidence rates for No. 10 LN metastasis in the validation set (P > 0.05). Conclusion The scoring system comprising the tumor size, preoperative T stage and N stage is a simple and effective method to predict the risk of No. 10 LN metastasis and to preoperatively select cases suitable for laparoscopic spleen-preserving SHLND.
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Affiliation(s)
- Zhi-Liang Hong
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Ru-Hong Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
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van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
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Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
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Kummer A, Hahnloser D, Demartines N, Hübner M. Comparison of Functional Recovery is Crucial for Implementing ERAS: Reply. World J Surg 2016; 41:322-323. [PMID: 27658804 DOI: 10.1007/s00268-016-3717-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- A Kummer
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - D Hahnloser
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - N Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - M Hübner
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Predicting opportunities to increase utilization of laparoscopy for colon cancer. Surg Endosc 2016; 31:1855-1862. [PMID: 27572064 DOI: 10.1007/s00464-016-5185-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/13/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite proven safety and efficacy, rates of minimally invasive approaches for colon cancer remain low in the USA. Given the known benefits, investigating the root causes of underutilization and methods to increase laparoscopy is warranted. Our goal was to develop a predictive model of factors impacting use of laparoscopic surgery for colon cancer. METHODS The Premier Hospital Database was reviewed for elective colorectal resections for colon cancer (2009-2014). Patients were identified by ICD-9-CM diagnosis code and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes. An adjusted multivariate logistic regression model identified variables predictive of use of laparoscopy for colon cancer. RESULTS A total of 24,245 patients were included-12,523 (52 %) laparoscopic and 11,722 (48 %) open. General surgeons performed the majority of all procedures (77.99 % open, 71.60 % laparoscopic). Overall use of laparoscopy increased from 48.94 to 52.03 % over the study period (p < 0.0001). Patients with private insurance were more likely to have laparoscopy compared with Medicare patients (adjusted odds ratio (OR) 1.089, 95 % CI [1.004, 1.181], p = 0.0388). Higher volume of surgeons (OR 3.518, 95 % CI [2.796, 4.428], p < 0.0001) and larger hospitals by bed size were more likely to approach colon cancer laparoscopically. Colorectal surgeons were 32 % more likely to approach a case laparoscopically than general surgeons (OR 1.315, 95 % CI [1.222, 1.415], p < 0.0001). Teaching hospitals, hospitals in the Midwest, and hospitals with less than 500 beds were less likely to use laparoscopy. CONCLUSIONS There are patient, provider, and hospital characteristics that can be identified preoperatively to predict who will undergo surgery for colon cancer using laparoscopy. However, additional patients may be eligible for laparoscopy based on patient-level characteristics. These results have implications for regionalization and increasing teaching of MIS. Recognizing and addressing these variables with training and recruiting could increase use of minimally invasive approaches, with the associated clinical and financial benefits.
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Shanker BA, Soliman M, Williamson P, Ferrara A. Laparoscopic Colorectal Training Gap in Colorectal and Surgical Residents. JSLS 2016; 20:e2016.00024. [PMID: 27493468 PMCID: PMC4949352 DOI: 10.4293/jsls.2016.00024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Laparoscopic colorectal surgery is an established safe procedure with demonstrated benefits. Proficiency in this specialty correlates with the volume of cases. We examined training in this surgical field for both general surgery and colon and rectal surgery residents to determine whether the number of cases needed for proficiency is being realized. METHODS We examined the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Colorectal Surgeons (ABCRS) operative statistics for graduating general surgery and colon and rectal surgery residents. RESULTS Although the number of advanced laparoscopy cases had increased for general surgery residents, there was still a significant gap in case volume between the average number of laparoscopic colorectal operations performed by graduating general surgery residents (21.6) and those performed by graduating colon and rectal surgery residents (81.9) in 2014. CONCLUSION There is a gap between general surgery and colon and rectal surgery residency training for laparoscopic colorectal surgery. General surgery residents are not meeting the volume of cases necessary for proficiency in colorectal surgery. This deficit represents a structural difference in training.
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Affiliation(s)
| | - Mark Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida, USA
| | | | - Andrea Ferrara
- Colon and Rectal Clinic of Orlando, Orlando, Florida, USA
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Wyles SM, Miskovic D, Ni Z, Darzi AW, Valori RM, Coleman MG, Hanna GB. Development and implementation of the Structured Training Trainer Assessment Report (STTAR) in the English National Training Programme for laparoscopic colorectal surgery. Surg Endosc 2015; 30:993-1003. [DOI: 10.1007/s00464-015-4281-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
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Mackenzie H, Ni M, Miskovic D, Motson RW, Gudgeon M, Khan Z, Longman R, Coleman MG, Hanna GB. Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery. Br J Surg 2015; 102:991-7. [DOI: 10.1002/bjs.9828] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes.
Methods
Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis.
Results
Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P < 0·001).
Conclusion
An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.
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Affiliation(s)
- H Mackenzie
- Department of Surgery and Cancer, Imperial College, London, UK
| | - M Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | - D Miskovic
- John Goligher Colorectal Unit, Leeds Teaching Hospitals, Leeds, UK
| | - R W Motson
- ICENI Centre, Colchester Hospital, Colchester, UK
| | - M Gudgeon
- Colorectal Unit, Frimley Park Hospital, Frimley, UK
| | - Z Khan
- Colorectal Unit, Queen Elizabeth Hospital, King's Lynn, UK
| | - R Longman
- Colorectal Unit, Bristol Royal Infirmary, Bristol, UK
| | - M G Coleman
- Colorectal Unit, Derriford Hospital, Plymouth, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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