Successful and safe introduction of laparoscopic colorectal cancer surgery in Dutch hospitals

Minimally Invasive Surgery for Colorectal Cancer: Benchmarking Uptake for a Regional Improvement Programme

BACKGROUND

The uptake of minimally invasive surgery (MIS) for patients with colorectal cancer has progressed at differing rates, both across countries, and within countries. This study aimed to investigate uptake for a regional colorectal cancer improvement programme in England.

METHOD

We calculated the proportion of patients receiving elective laparoscopic and robot-assisted surgery amongst those diagnosed with colorectal cancer over 3 time periods (2007-2011, 2012-2016 and 2017-2021) in hospitals participating in the Yorkshire Cancer Research Bowel Cancer Improvement Programme (YCR BCIP). These were benchmarked against national rates. Regression analysis and funnel plots were used to develop a data driven approach for analysing trends in the use of MIS at hospitals in the programme.

RESULTS

In England, resections performed by MIS increased from 34.9% to 72.9% for colon cancer and from 28.8% to 72.5% for rectal cancer. Robot-assisted surgery increased from 0.1% to 2.7% for colon cancer and from 0.2% to 7.9% for rectal cancer. Wide variation in the uptake of MIS was observed at a hospital level. Detailed analysis of the YCR BCIP region identified a decreasing number of surgical departments, since the start of the programme, as potential outliers for MIS when compared to the English national average.

CONCLUSION

Wide variation in use of MIS for colorectal cancer exists within the English National Health Service and a data-driven approach can help identify outlying hospitals. Addressing some of the challenges behind the uptake of MIS, such as ensuring adequate provision of surgical training and equipment, could help increase its use.

Evaluation and analysis of neurocognitive dysfunction in patients with colorectal cancer after radical resection: A retrospective study

BACKGROUND

With the continuous progress of colorectal cancer treatment technology, the survival rate of patients has improved significantly, but the problem of postoperative neurocognitive dysfunction has gradually attracted attention.

AIM

To analyze the risk factors for delayed postoperative neurocognitive recovery (DNR) after laparoscopic colorectal cancer surgery and constructed a risk prediction model to provide an evidence-based reference for the prevention and treatment of DNR after laparoscopic colorectal cancer surgery.

METHODS

The clinical data of 227 patients with colorectal cancer who underwent laparoscopic surgery and regional cerebral saturation oxygenation (rScO2) monitoring at our hospital from March 2020 to July 2022 were retrospectively analyzed. Common factors and potential factors affecting postoperative DNR were used as analysis variables, and univariate analysis and multifactor analysis were carried out step by step to determine the predictors of the model and construct a risk prediction model. The predictive performance of the model was assessed by the receiver operating characteristic (ROC) curve, the calibration curve was used to assess the fit of the model to the data, and a nomogram was drawn. In addition, 30 patients who met the inclusion and exclusion criteria from January 2023 to July 2023 were selected for external verification of the prediction model.

RESULTS

The incidence of postoperative DNR in the modeling group was 15.4% (35/227). Multivariate analysis revealed that age, years of education, diabetes status, and the lowest rScO2 value were the independent influencing factors of postoperative DNR (all P < 0.05). Accordingly, a DNR risk prediction model was constructed after laparoscopic colorectal cancer surgery. The area under the ROC curve of the model was 0.757 (95%CI: 0.676-0.839, P < 0.001), and the Hosmer-Lemeshow test of the calibration curve suggested that the model was well fitted (P = 0.516). The C-index for external validation of the row was 0.617.

CONCLUSION

The DNR risk prediction model associated with rScO2 monitoring can be used for individualized assessment of patients undergoing laparoscopic colorectal cancer surgery and provides a clinical basis for the prevention of DNR after surgery.

Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open

BACKGROUND

The aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting.

METHODS

All 9,464 patients diagnosed with rectal cancer 2012-2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry.

PRIMARY OUTCOMES

Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%.

SECONDARY OUTCOMES

30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses.

RESULTS

The CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS.

CONCLUSIONS

In this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.

A machine learning model to predict the need for conversion of operative approach in patients undergoing colectomy for neoplasm

BACKGROUND

Studies comparing conversion from laparoscopic to open approaches to colectomy have found an association between conversion and morbidity, mortality, and length of stay, suggesting that certain patients may benefit from an open approach "up-front."

AIM

The objective of this study was to use machine learning algorithms to develop a model enabling the prediction of which patients are likely to require conversion.

METHODS AND RESULTS

We used ACS NSQIP data to identify patients undergoing colectomy (2014-2019). We included patients undergoing elective colectomy for colorectal neoplasm via a minimally invasive approach or a converted approach. The outcome of interest was conversion. Variables were included in the model based on their correlation with conversion by logistic regression (p < .05). Two models were used: weighted logistic regression with regularization, and Random Forest classifier. The data was randomly split into training (70%) and test (30%) cohorts, and prediction performance was calculated. 24 327 cases were included (17 028 training, 7299 test). When applied to the test cohort, the models had an accuracy of 0.675 (range 0.65-0.70) in predicting conversion; c-index ranged from 0.62-0.63. This machine learning model achieved a moderate area under the curve and a high negative predictive value, but a low positive predictive value; therefore, this model can predict (with 95% accuracy) whether a colectomy for neoplasm can be successfully completed using a minimally invasive approach.

CONCLUSION

This model can be used to reassure surgeons of the appropriateness of a minimally invasive approach when planning for an elective colectomy.

A prediction model to refine the timing of an early second-look laparoscopic exploration in patients with colon cancer at high risk of early peritoneal metastasis recurrence

BACKGROUND

In patients at high risk of peritoneal metastasis (PM) recurrence following surgical treatment of colon cancer (CC), second-look laparoscopic exploration (SLLE) is mandatory; however, the best timing is unknown. We created a tool to refine the timing of early SLLE in patients at high risk of PM recurrence.

METHODS

This international cohort study included patients who underwent CC surgery between 2009 and 2020. All patients had PM recurrence. Factors associated with PM-free survival (PMFS) were assessed using Cox regression. The primary endpoint was early PM recurrence defined as a PMFS of <6 months. A model (logistic regression) was fitted and corrected using bootstrap.

RESULTS

In total, 235 patients were included. The median PMFS was 13 (IQR, 8-22) months, and 15.7% of the patients experienced an early PM recurrence. Synchronous limited PM and/or ovarian metastasis (hazard ratio [HR]: 2.50; 95% confidence interval [CI]: [1.66-3.78]; p < 0.001) were associated with a very high-risk status requiring SLLE. T4 (HR: 1.47; 95% CI: [1.03-2.11]; p = 0.036), transverse tumor localization (HR: 0.35; 95% CI: [0.17-0.69]; p = 0.002), emergency surgery (HR: 2.06; 95% CI: [1.36-3.13]; p < 0.001), mucinous subtype (HR: 0.50; 95% CI [0.30, 0.82]; p = 0.006), microsatellite instability (HR: 2.29; 95% CI [1.06, 4.93]; p = 0.036), KRAS mutation (HR: 1.78; 95% CI: [1.24-2.55]; p = 0.002), and complete protocol of adjuvant chemotherapy (HR: 0.93; 95% CI: [0.89-0.96]; p < 0.001) were also prognostic factors for PMFS. Thus, a model was fitted (area under the curve: 0.87; 95% CI: [0.82-0.92]) for prediction, and a cutoff of 150 points was identified to classify patients at high risk of early PM recurrence.

CONCLUSION

Using a nomogram, eight prognostic factors were identified to select patients at high risk for early PM recurrence objectively. Patients reaching 150 points could benefit from an early SLLE.

Possible Advantages of Minimal-Invasive Approaches in Rectal Cancer Surgery: A Nationwide Analysis

(1) Background: Laparoscopic resection for colon and rectal cancer was introduced in the early 1990s; the aim of this analysis was to show possible advantages of minimal-invasive approaches in rectal cancer surgery. (2) Methods: From 2016 to 2020, all patients undergoing open, laparoscopic or robotic-assisted rectal cancer surgery in Germany were retrospectively analyzed regarding sex distribution, conversion rates and in-hospital mortality rates according to nationwide hospital billing data based on diagnosis-related groups (DRGs). (3) Results: In total, 68,112 patients were analyzed, and most commonly, low anterior rectal resections with primary anastomosis (n = 25,824) were performed with an increase of minimal-invasive procedures over the years (open: 51% to 27%; laparoscopic: 47% to 63% and robotic: 2% to 10%). In-hospital mortality rate was 2.95% (n = 2012). In total, 4.61%, 1.77%, 1.14% and 3.95% of patients with open, laparoscopic, robotic and converted-to-open surgery died during hospital stay, respectively (open vs. laparoscopic p < 0.0001; open vs. robotic p < 0.00001; laparoscopic vs. robotic p = 0.001). Conversion rates were significantly more favorable in the robotic compared to the laparoscopic group. (11.94% vs. 2.53%; p < 0.0001). (4) Conclusion: Minimal-invasive rectal cancer surgery might have some advantages in terms of a reduced in-hospital mortality, and an improved conversion rate for the robotic approach.

OUP accepted manuscript

Background

As the outcome of modern colorectal cancer (CRC) surgery has significantly improved over the years, however, renewed and adequate risk stratification for mortality is important to identify high-risk patients. This population-based study was conducted to analyse postoperative outcomes in patients with CRC and to create a risk model for 30-day mortality.

Methods

Data from the Dutch Colorectal Audit were used to assess differences in postoperative outcomes (30-day mortality, hospital stay, blood transfusion, postoperative complications) in patients with CRC treated from 2009 to 2017. Time trends were analysed. Clinical variables were retrieved (including stage, age, sex, BMI, ASA grade, tumour location, timing, surgical approach) and a prediction model with multivariable regression was computed for 30-day mortality using data from 2009 to 2014. The predictive performance of the model was tested among a validation cohort of patients treated between 2015 and 2017.

Results

The prediction model was obtained using data from 51 484 patients and the validation cohort consisted of 32 926 patients. Trends of decreased length of postoperative hospital stay and blood transfusions were found over the years. In stage I–III, postoperative complications declined from 34.3 per cent to 29.0 per cent (P < 0.001) over time, whereas in stage IV complications increased from 35.6 per cent to 39.5 per cent (P = 0.010). Mortality decreased in stage I–III from 3.0 per cent to 1.4 per cent (P < 0.001) and in stage IV from 7.6 per cent to 2.9 per cent (P < 0.001). Eight factors, including stage, age, sex, BMI, ASA grade, tumour location, timing, and surgical approach were included in a 30-day mortality prediction model. The results on the validation cohort documented a concordance C statistic of 0.82 (95 per cent c.i. 0.80 to 0.83) for the prediction model, indicating good discriminative ability.

Conclusion

Postoperative outcome improved in all stages of CRC surgery in the Netherlands. The developed model accurately predicts postoperative mortality risk and is clinically valuable for decision-making.

Failure to rescue following proctectomy for rectal cancer: the additional benefit of laparoscopic approach in a nationwide observational study of 44,536 patients

BACKGROUND

There is growing evidence that failure to rescue (FTR) is an important factor of postoperative mortality (POM) after rectal cancer surgery and surgical approach modified post-operative outcomes. However, the impact of laparoscopy on FTR after proctectomy for rectal cancer remains unknown. The aim of this study was to compare the rates of postoperative complications and FTR after laparoscopy vs open proctectomy for cancer.

METHODS

All patients who underwent proctectomy for rectal cancer between 2012 and 2016 were included. FTR was defined as the 90-day POM rate among patients with major complications. Outcomes of patients undergoing open or laparoscopic rectal cancer surgery were compared after 1:1 propensity score matching by year of surgery, hospital volume, sex, age, Charlson score, neoadjuvant chemotherapy, tumor localization and type of anastomosis.

RESULTS

Overall, 44,536 patients who underwent proctectomy were included, 7043 of whom (15.8%) developed major complications. The rates of major complications, POM and FTR were significantly higher in open compared to laparoscopic procedure (major complications: 19.2% vs 13.7%, p < 0.001; POM: 5.4% vs 2.3%, p < 0.001; FTR: 13.6% vs 8.3%, p < 0.001; respectively). After matching, open and laparoscopic groups were comparable. Multivariate analysis showed that age, Charlson score, sphincter-preserving procedure and surgical approach were predictive factors for FTR. Open proctectomy was found to be a risk factor for FTR (OR 1.342, IC95% [1.066; 1.689], p = 0.012) compared to laparoscopic procedure.

CONCLUSION

When complications occurred, patients operated on by open proctectomy were more likely to die.

[Evidence in minimally invasive oncological surgery of the colon and rectum]

An essential component of the treatment of colorectal cancer is a resection of the tumor-bearing segment of the bowels. After the development of minimally invasive procedures the feasibility and safety in oncological, colorectal surgery was questioned. The broad study situation for colon cancer over the last years showed predominantly consistent benefits during the perioperative phase and non-inferiority concerning long-term oncological outcomes. The implementation of laparoscopic rectal resection was more hesitant due to the complexity of the procedure and insufficient study data; however, overall the short-term benefits seem to be maintained and laparoscopic rectal resection is thought to be noninferior to open resection in the long run even though findings on the quality of the resected specimen are heterogeneous. Accordingly, most guidelines now include a recommendation of laparoscopic resection for colorectal cancer. The limitation with respect to an achievable oncological equivalency of resection takes account of the complexity and the requirements of the intervention only in the setting of rational selection of patients and sufficient experience of the surgeon.

Predictors of 30-Day Mortality Among Dutch Patients Undergoing Colorectal Cancer Surgery, 2011-2016

IMPORTANCE

Quality improvement programs for colorectal cancer surgery have been introduced with benchmarking based on quality indicators, such as mortality. Detailed (pre)operative characteristics may offer relevant information for proper case-mix correction.

OBJECTIVE

To investigate the added value of machine learning to predict quality indicators for colorectal cancer surgery and identify previously unrecognized predictors of 30-day mortality based on a large, nationwide colorectal cancer registry that collected extensive data on comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

All patients who underwent resection for primary colorectal cancer registered in the Dutch ColoRectal Audit between January 1, 2011, and December 31, 2016, were included. Multiple machine learning models (multivariable logistic regression, elastic net regression, support vector machine, random forest, and gradient boosting) were made to predict quality indicators. Model performance was compared with conventionally used scores. Risk factors were identified by logistic regression analyses and Shapley additive explanations (ie, SHAP values). Statistical analysis was performed between March 1 and September 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome of this cohort study was 30-day mortality. Prediction models were trained on a training set by performing 5-fold cross-validation, and outcomes were measured by the area under the receiver operating characteristic curve on the test set. Machine learning was further used to identify risk factors, measured by odds ratios and SHAP values.

RESULTS

This cohort study included 62 501 records, most patients were male (35 116 [56.2%]), were aged 61 to 80 years (41 560 [66.5%]), and had an American Society of Anesthesiology score of II (35 679 [57.1%]). A 30-day mortality rate of 2.7% (n = 1693) was found. The area under the curve of the best machine learning model for 30-day mortality (0.82; 95% CI, 0.79-0.85) was significantly higher than the American Society of Anesthesiology score (0.74; 95% CI, 0.71-0.77; P < .001), Charlson Comorbidity Index (0.66; 95% CI, 0.63-0.70; P < .001), and preoperative score to predict postoperative mortality (0.73; 95% CI, 0.70-0.77; P < .001). Hypertension, myocardial infarction, chronic obstructive pulmonary disease, and asthma were comorbidities with a high risk for increased mortality. Machine learning identified specific risk factors for a complicated course, intensive care unit admission, prolonged hospital stay, and readmission. Laparoscopic surgery was associated with a decreased risk for all adverse outcomes.

CONCLUSIONS AND RELEVANCE

This study found that machine learning methods outperformed conventional scores to predict 30-day mortality after colorectal cancer surgery, identified specific patient groups at risk for adverse outcomes, and provided directions to optimize benchmarking in clinical audits.

Comparison of Chief Surgeons' and Assistants' Feelings of Fatigue Between Laparoendoscopic Single-site and Conventional Laparoscopic Adrenalectomy

BACKGROUND

Our objective was to compare the surgical staff's feelings of fatigue between laparoendoscopic single-site adrenalectomy (LESS-A) and conventional laparoscopic adrenalectomy (CLA) before and after surgery.

METHOD

Data were collected for surgical procedures performed between June 2011 and September 2017 (57 LESS-A and 37 CLA). Each procedure in both groups was performed by the same chief surgeon. The subjective fatigue feelings of the key members of the surgical team (chief surgeon, scopist, assistant surgeon) were assessed using the "Jikaku-sho shirabe" questionnaire, which contained questions about work-related feelings of fatigue. It consisted of 25 subjective items for 5 factors drawn from factor analysis (drowsiness, instability, uneasiness, local pain or dullness, and eyestrain). For each item, the participants were requested to estimate the intensity of their feelings using a five-point rating scale before and after surgery.

RESULTS

There was no significant difference in operative time (p = 0.231) between the LESS-A and CLA procedure groups. For the chief surgeon, local pain or dullness (p = 0.603) and eyestrain (p = 0.086) were similar between the LESS-A and CLA procedures. The scopists and assistant surgeons in the LESS-A group did not suffer local pain or dullness (p = 0.793 and p = 0.240, respectively). They did, however, suffer more eyestrain than those in the CLA group (p = 0.001 and p = 0.001, respectively).

CONCLUSION

Although LESS-A is generally considered to be a technically difficult procedure, the results of this study demonstrate that the feelings of physical fatigue are roughly equivalent between LESS-A and CLA procedures.

A 10-Year Evaluation of Short-Term Outcomes After Synchronous Colorectal Cancer Surgery: a Dutch Population-Based Study

BACKGROUND

Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and introduction of screening on these outcomes remains unknown. This study aimed to evaluate time trends in incidence, population characteristics, and short-term outcomes of synchronous CRC patients at the population level over a 10-year time period.

METHODS

Data of all patients that underwent resection for primary CRC were extracted from the Dutch ColoRectal Audit (2010-2019). Analyses were stratified for solitary and synchronous colon and rectal cancer. Multilevel logistic regression analyses were used to determine factors associated with pathological and surgical outcomes.

RESULTS

Among 100,474 patients, 3.1% underwent surgery for synchronous CRC. A screening-related decrease for surgically treated left-sided solitary and synchronous colon cancer and a temporary increase for exclusively right-sided colon cancer were observed. Synchronous CRC patients had higher rates of complicated postoperative course, failure to rescue, and mortality. Bilateral synchronous colon cancer was more often treated with subtotal colectomy (25.4%) and demonstrated higher rates of surgical complications, reinterventions, prolonged hospital stay, and mortality than other synchronous tumor locations.

DISCUSSION

National bowel screening resulted in contradictory effects on surgical resections for synchronous CRCs depending on sidedness. Bilateral synchronous colon cancer required more often extended resection resulting in significantly worse outcomes than other synchronous tumor locations. Identification of low volume, high complex CRC subpopulations is relevant for individualized care and has implications for case-mix correction and benchmarking in clinical auditing.

Laparoscopic surgery for colon cancer

Background

To evaluate a new procedure in daily clinical practice, it might not be sufficient to rely exclusively on the findings of randomized clinical trials (RCTs). This is the first systematic review providing a synthesis of the most important RCTs and relevant retrospective cohort studies on short- and long-term outcomes of laparoscopic surgery in colon cancer patients.

Materials and methods

In a literature search, more than 1800 relevant publications on the topic were identified. Relevant RCTs and representative high-quality retrospective studies were selected based on the widely accepted Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Finally, 9 RCTs and 14 retrospective cohort studies were included.

Results

Laparoscopic surgery for colon cancer is associated with a slightly longer duration of surgery, but a variety of studies show an association with a lower rate of postoperative complications and a shorter duration of hospital stay. Particularly in older patients with more frequent comorbidities, laparoscopy seems to contribute to decreasing postoperative mortality. Concerning long-term oncologic outcomes, the laparoscopic and open techniques were shown to be at least equivalent.

Conclusion

The findings of the existing relevant RCTs on laparoscopic surgery for colon cancer are mostly confirmed by representative retrospective cohort studies based on real-world data; therefore, its further implementation into clinical practice can be recommended.

Comparison of Systematic Video Documentation With Narrative Operative Report in Colorectal Cancer Surgery

Importance

Despite ongoing advances in the field of colorectal surgery, the quality of surgical treatment is still variable. As an intrinsic part of surgical quality, the technical information regarding the surgical procedure is reflected only by the narrative operative report (NR), which has been found to be subjective and regularly omits important information.

Objective

To investigate systematic video recording (SVR) as a potential improvement in quality and safety with regard to important information in colorectal cancer surgery.

Design, Setting, and Participants

The Imaging for Quality Control Trial was a prospective, observational cohort study conducted between January 12, 2016, and October 30, 2017, at 3 centers in the Netherlands. The study group consisted of 113 patients 18 years or older undergoing elective laparoscopic surgery for colorectal cancer. These patients were case matched and compared with cases from a historical cohort that received only an NR.

Interventions

Among study cases, participating surgeons were requested to systematically capture predefined key steps of the surgical procedure intraoperatively on video in short clips.

Main Outcomes and Measures

The SVRs and NRs were analyzed for adequacy with respect to the availability of important information regarding the predefined key steps. Adequacy of the reported information was defined as the proportion of key steps with available and sufficient information in the report. Adequacy of the SVR and NR was compared between the study and control groups, with the SVR alone and as an adjunct to the NR in the study group vs NR alone in the control group.

Results

Of the 113 study patients, 69 women (61.1%) were included; mean (SD) age was 66.3 (9.8) years. In the control group, a mean (SD) of 52.5% (18.3%) of 631 steps were adequately described in the NR. In the study group, the adequacy of both the SVR (78.5% [16.5%], P < .001) and a combination of the SVR with NR (85.1% [14.6%], P < .001) was significantly superior to NR alone. The only significant difference between the study and historical control groups regarding postoperative and pathologic outcomes was a shorter postoperative mean (SD) length of stay in favor of the study group (8.0 [7.7] vs 8.6 [6.8] days; P = .03).

Conclusions and Relevance

Use of SVR in laparoscopic colorectal cancer surgery as an adjunct to the NR might be superior in documenting important steps of the operation compared with NR alone, adding to the overall availability of necessary intraoperative information and contributing to quality control and objectivity.

Laparoscopic colectomy: trends in implementation in Canada and globally

Summary

Comparisons with other high-income countries suggest that Canada has been slower to adopt laparoscopic colectomy (LC). The Canadian Association of General Surgeons sought to evaluate the barriers to adoption of laparoscopic colon surgery and to propose potential intervention strategies to enhance the use of the procedure. Given the clinical benefits of laparoscopic surgery for patients, the increasing needs for surgical care and the desire of Canadian general surgeons to advance their specialty and enhance the care of their patients, it is an important priority to improve the utilization of LC.

Low Incidence of Advanced Neoplasia in Serrated Polyposis Syndrome After (Sub)total Colectomy: Results of a 5-Year International Prospective Cohort Study

INTRODUCTION

Serrated polyposis syndrome (SPS) is accompanied by a substantially increased colorectal cancer (CRC) risk. To prevent or treat CRC in patients with a very high polyp burden, (sub)total colectomy with ileorectal or ileosigmoidal anastomosis is regularly performed. The CRC risk after (sub)total colectomy might be decreased, but evidence is lacking. We aimed to assess the yield of endoscopic surveillance in patients with SPS who underwent (sub)total colectomy.

METHODS

For this post hoc analysis, we used prospectively collected data from a large international prospective cohort study. We included patients diagnosed with SPS (World Health Organization type I and/or III) who underwent (sub)total colectomy. Primary endpoint was the cumulative 5-year incidence of CRC and advanced neoplasia (AN).

RESULTS

Forty-eight patients (mean age 61 [±7.8]; 52% men) were included and followed up for a median of 4.7 years (interquartile range 4.7-5.1). None of the patients developed CRC during follow-up. Five patients developed AN, corresponding to a cumulative 5-year AN incidence of 13% (95% confidence interval 1.2-23). In 4 patients, AN was diagnosed at the first surveillance endoscopy after study inclusion, and in 1 patient, AN was detected during subsequent rounds of surveillance. The risk of AN was similar for patients with ileorectal and ileosigmoidal anastomosis (logrank P = 0.83).

DISCUSSION

(Sub)total colectomy mitigates much of the excess risk of CRC in patients with SPS. Advanced neoplasms are mainly detected at the first endoscopy after (sub)total colectomy. Based on these results, after the first surveillance, intervals might be extended beyond the currently recommended 1-2 years.

Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions

Background

A multicentre cohort study was performed to analyse the motivations for surgical referral of patients with benign colorectal lesions, and to evaluate the endoscopic and pathological characteristics of these lesions as well as short‐term surgical outcomes.

Methods

Patients who underwent surgery for a benign colorectal lesion in 15 Dutch hospitals between January 2014 and December 2017 were selected from the pathology registry. Lesions were defined as complex when at least one of the following features was present: size at least 40 mm, difficult location according to the endoscopist, previous failed attempt at resection, or non‐lifting sign.

Results

A total of 358 patients were included (322 colonic and 36 rectal lesions). The main reasons for surgical referral of lesions in the colon and rectum were large size (33·5 and 47 per cent respectively) and suspicion of invasive growth (31·1 and 58 per cent). Benign lesions could be categorized as complex in 80·6 per cent for colonic and 80 per cent for rectal locations. Surgery consisted of local excision in 5·9 and 64 per cent of colonic and rectal lesions respectively, and complicated postoperative course rates were noted in 11·2 and 3 per cent. In the majority of patients, no attempt was made to resect the lesion endoscopically (77·0 per cent of colonic and 83 per cent of rectal lesions).

Conclusion

The vast majority of the benign lesions referred for surgical resection could be classified as complex. Considering the substantial morbidity of surgery for benign colonic lesions, reassessment for endoscopic resection by another advanced endoscopy centre seems to be underused and should be encouraged.

Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort

Background

Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue.

Methods

The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis.

Results

Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012).

Conclusion

Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.

Laparoscopic and open resection of rectal cancer-is age an effect modifier for short- and long-term survival?

INTRODUCTION

Rectal cancer is a frequently diagnosed tumor worldwide. Various studies have shown the noninferiority or even slight superiority of laparoscopic resection. However, there is no clear recommendation on whether age should influence the choice of surgical approach.

MATERIALS AND METHODS

This study compared outcomes of laparoscopic and open surgery in rectal cancer patients. Perioperative mortality and 5-year overall, relative, and recurrence-free survival rates were analyzed separately for three age groups. Data originate from 30 regional German cancer registries that cover approximately one quarter of the German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were used; a sensitivity analysis assessed bias by exclusion.

RESULTS

Ten thousand seven hundred fifty-four patients were included in the analysis. The mean laparoscopy rate was 23.0% and increased over time. Analysis of 30-day postoperative mortality rates revealed advantages for laparoscopically treated patients, although the significance level was not reached in any age group. Regarding 5-year overall survival, laparoscopy generally seems to be the superior approach, whereas for recurrence-free survival, an age-dependent gradient in effect size was observed: with a hazard ratio (HR) of 0.703 for laparoscopy, patients under 60 years benefitted more from the minimally invasive approach than older patients (septuagenarians, HR 0.923).

CONCLUSION

Laparoscopy shows similar results to the open approach in terms of postoperative survival in all age groups. Concerning long-term outcomes, younger patients benefitted most from the minimally invasive approach.

Multicenter Observational Study of Adhesion Formation After Open-and Laparoscopic Surgery for Colorectal Cancer

OBJECTIVE

The aim of this study was to compare adhesion formation after laparoscopic and open colorectal cancer resection.

SUMMARY OF BACKGROUND DATA

After colorectal surgery, most patients develop adhesions, with a high burden of complications. Laparoscopy seems to reduce adhesion formation, but evidence is poor. Trials comparing open- and laparoscopic colorectal surgery have never assessed adhesion formation.

METHODS

Data on adhesions were gathered during resection of colorectal liver metastases. Incidence of adhesions adjacent to the original incision was compared between patients with previous laparoscopic- and open colorectal resection. Secondary outcomes were incidence of any adhesions, extent and severity of adhesions, and morbidity related to adhesions or adhesiolysis.

RESULTS

Between March 2013 and December 2015, 151 patients were included. Ninety patients (59.6%) underwent open colorectal resection and 61 patients (40.4%) received laparoscopic colorectal resection. Adhesions to the incision were present in 78.9% after open and 37.7% after laparoscopic resection (P < 0.001). The incidence of abdominal wall adhesions and of any adhesion was significantly higher after open resection; the incidence of visceral adhesions did not significantly differ. The extent of abdominal wall and visceral adhesions and the median highest Zühlke score at the incision were significantly higher after open resection. There were no differences in incidence of small bowel obstruction during the interval between the colorectal and liver operations, the incidence of serious adverse events, and length of stay after liver surgery.

CONCLUSION

Laparoscopic colorectal cancer resection is associated with a lower incidence, extent, and severity of adhesions to parietal surfaces. Laparoscopy does not reduce the incidence of visceral adhesions.

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

AIM

The oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia (Spain).

METHODS

This was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years.

RESULTS

Of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery.

CONCLUSIONS

Laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials.

Structured training program in colorectal surgery: the robotic surgeon as a new paradigm

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.

The prevalence of musculoskeletal injuries in bariatric surgeons

OBJECTIVE

To investigate the prevalence of musculoskeletal (MSK) injuries in bariatric surgeons around the world.

BACKGROUND

As the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. However, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a 73-88% prevalence of physical complaints in surgeons performing laparoscopic surgeries.

METHODS

A web-based survey was designed and sent out to bariatric surgeons around the world. Participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and MSK injuries.

RESULTS

There were 113 responses returned from surgeons from 34 countries around the world. 68.5% of the surgeons have had more than 10 years of experience in laparoscopic surgery, 65.8% in open, and 0.9% in robotic surgery. 66% of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in 27.2% of the surgeons. It was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. A higher percentage of females than males reported pain in the neck, back, and shoulder area when performing laparoscopic procedures. Supine positioning of patients evoked more discomfort in the wrists, while the French position caused more discomfort in the back region. A higher percentage of surgeons who did not exercise experienced more issues in the neck and back region, while those that exercised more than 3 h a week experienced issues in their shoulders and wrists in both open and laparoscopic approaches. Only 57.7% sought medical treatment for their MSK problem, of which 6.35% had to undergo surgery for their issue, of which 55.6% of those felt that the treatment resolved their problem.

CONCLUSION

MSK injuries and pain are a common occurrence among the population of bariatric surgeons (66%), and has the ability to hinder performance at work. Therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.

Uptake of elective laparoscopic colectomy for colon cancer in Canada from 2004/05 to 2014/15: a descriptive analysis

BACKGROUND

Evidence from randomized controlled trials published since 2004 shows that elective laparoscopic colectomy for colon cancer improves short-term postoperative outcomes with equivalent oncologic outcomes compared to open colectomy. The objective of this study was to examine the uptake of elective laparoscopic colectomy in Canada and compare its use among Canadian provinces.

METHODS

In this descriptive analysis, we identified from hospital discharge abstracts all patients in the Canadian provinces (except Quebec) who underwent elective colectomy for colon cancer between 2004/05 and 2014/15. We compared temporal changes in the proportion of patients who underwent laparoscopic colectomy or open colectomy among provinces using logistic regression.

RESULTS

Of 63 504 patients who underwent elective colectomy between 2004/05 and 2014/15, 19 691 (31.0%) underwent laparoscopic colectomy. The annual proportion of patients who underwent laparoscopic colectomy increased from 9.2% in 2004/05 to 51.5% in 2014/15 (mean annual percent increase 4.2%). There were significant differences between provinces in the overall proportion of patients who underwent laparoscopic colectomy (p < 0.001), ranging from 7.6% in Newfoundland and Labrador to 36.9% in Ontario. By 2014/15, most colectomy procedures were performed laparoscopically in 3 provinces; British Columbia (60.2%), Ontario (59.4%) and Alberta (53.1%). In addition to year and province, urban residence, younger age, female sex, fewer medical comorbidities, high surgeon volume, high hospital volume and right-sided tumours were significantly associated with increased likelihood of laparoscopic colectomy.

INTERPRETATION

Although the use of laparoscopic colectomy increased rapidly between 2004/05 and 2014/15 in Canada, substantial interprovincial variation exists. Further knowledge-translation strategies are needed to ensure equal access to laparoscopic colectomy for all Canadians.

Achievements in colorectal cancer care during 8 years of auditing in The Netherlands

INTRODUCTION

The efficacy of auditing is still a subject of debate and concerns exist whether auditing promotes risk averse behaviour of physicians. This study evaluates the achievements made in colorectal cancer surgery since the start of a national clinical audit and assesses potential signs of risk averse behaviour.

METHODS

Data were extracted from the Dutch ColoRectal Audit (2009-2016). Trends in outcomes were evaluated by uni and multivariable analyses. Patients were stratified according to operative risks and changes in outcomes were expressed as absolute (ARR) and relative risk reduction (RRR). To assess signs of risk averse behaviour, trends in stoma construction in rectal cancer were analysed.

RESULTS

Postoperative mortality decreased from 3.4% to 1.8% in colon cancer and from 2.3% to 1% in rectal cancer. Surgical and non-surgical complications increased, but with less reintervention. For colon cancer, the high-risk elderly patients had the largest ARR for complicated postoperative course (6.4%) and mortality (5.9%). The proportion of patients receiving a diverting stoma or end colostomy after a (L)AR decreased 11% and 7%, respectively. In low rectal cancer, patients increasingly received a non-diverted primary anastomosis (5.4% in 2011 and 14.4% in 2016).

CONCLUSIONS

No signs of risk averse behaviour was found since the start of the audit. Especially the high-risk elderly patients seem to have benefitted from improvements made in colon cancer treatment in the past 8 years. For rectal cancer, trends towards the construction of more primary anastomoses are seen. Future quality improvement measures should focus on reducing surgical and non-surgical complications.

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes

BACKGROUND

Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach.

METHODS

The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data.

RESULTS

A total of 25,253 patients met inclusion criteria-21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality.

CONCLUSIONS

Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons

OBJECTIVE

The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training.

DESIGN

An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort.

SETTING/PARTICIPANTS

This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States.

RESULTS

The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach.

CONCLUSION

The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.

Long-term oncologic outcomes after laparoscopic versus open rectal cancer resection: a high-quality population-based analysis in a Southern German district

BACKGROUND

An increasing number of rectal carcinoma resections in Germany and worldwide are performed laparoscopically. The recently published COLOR II trial demonstrated the oncologic safety of this surgical approach. It remains unclear whether these findings can be transferred to clinical practice.

PATIENTS AND METHODS

This population-based retrospective cohort study aimed to evaluate 5-year overall, relative, disease-free, and local recurrence-free survival of rectal cancer patients treated by open surgery and laparoscopy. Data from a southern German region of 1.1 million inhabitants were collected by an official clinical cancer registry. All primary non-metastatic rectal adenocarcinoma cases with surgery between 2004 and 2013 were eligible for inclusion. To compare survival rates, Kaplan-Meier analyses, relative survival models, and multivariate Cox regression were applied; a sensitivity analysis assessed bias by exclusion.

RESULTS

Finally, 1507 patients with a median follow-up time of 7.1 years were included. Of these patients, 28.4% underwent laparoscopic procedures, with an increasing rate over time. Patients with tumors of the upper or middle rectum, younger patients, and patients of specialized colorectal cancer centers were more likely to undergo laparoscopy. After 5 years, 80.4% of laparoscopy patients were still alive, compared to 68.6% in the open group (p < 0.001). Moreover, laparoscopy was associated with superior local recurrence-free survival rates. This advantage was also significant in multivariate analysis (HR 0.70, 95% CI 0.52-0.92).

CONCLUSION

Laparoscopic rectal cancer surgery can be considered safe in daily clinical practice. This should be confirmed by future studies outside the setting of randomized trials.

Long-term oncologic outcomes after laparoscopic vs. open colon cancer resection: a high-quality population-based analysis in a Southern German district

Background

Over 20 years after the introduction of laparoscopic surgery for colon cancer, many surgeons still prefer the open approach. Whereas randomized controlled trials (RCTs) have proven the oncologic safety of laparoscopy, long-term data depicting daily clinical routine are scarce.

Methods

This population-based cohort study compares 5-year overall, relative, and recurrence-free survival rates after laparoscopic and open colon carcinoma surgery. Data derive from an independent German cancer registry encompassing all tumor patients within a political district of 1.1 million inhabitants. The final analysis included 2669 patients with major elective resection of primary non-metastatic colonic adenocarcinoma between January 1, 2004 and December 31, 2013. Survival rates were compared using Kaplan–Meier analyses, relative survival models, and multivariate Cox regression. Sensitivity analysis quantified selection bias.

Results

The proportion of laparoscopic procedures increased from 9.7 to 25.8% in 2011 and dropped again to 15.8% at the end of observation period. Laparoscopy patients were younger, had a lower tumor stage, and were more likely to receive postoperative chemotherapy. Overall, relative, and recurrence-free survival was significantly superior or equivalent in Kaplan–Meier analysis (5-year overall survival rate open vs. laparoscopic: 69.0 vs. 80.2%, p < 0.001). The superiority of laparoscopy mostly remained stable after adjusting for confounders, although significance was only reached in T1-3 patients without lymph node metastases (overall survival: hazard ratio (HR) 0.654; 95% confidence interval (CI) 0.446–0.958; p = 0.029).

Conclusion

Laparoscopy is a safe and promising alternative to the open approach in daily clinic practice. These favorable outcomes require future confirmation by high-quality studies outside the setting of RTCs.

Minimally Invasive versus Open Approach for Right-Sided Colectomy: A Study in 12,006 Patients from the Dutch Surgical Colorectal Audit

BACKGROUND

There is ongoing debate whether laparoscopic right colectomy is superior to open surgery. The purpose of this study was to address this issue and arrive at a consensus using data from a national database.

METHODS

Patients who underwent elective open or laparoscopic right colectomy for colorectal cancer during the period 2009-2013 were identified from the Dutch Surgical Colorectal Audit. Complications that occurred within 30 days after surgery and 30-day mortality rates were calculated and compared between open and laparoscopic resection.

RESULTS

In total, 12,006 patients underwent elective open or laparoscopic surgery for right-sided colorectal cancer. Of these, 6,683 (55.7%) underwent open resection and 5,323 (44.3%) underwent laparoscopic resection. Complications occurred within 30 days after surgery in the laparoscopic group in 26.1% of patients and in 32.1% of patients in the open group (p < 0.001). Thirty-day mortality was also significantly lower in the laparoscopic group (2.2 vs. 3.6% p < 0.001).

CONCLUSION

In this non-randomized, descriptive study conducted in the Netherlands, open right colectomy seems to have a higher risk for complications and mortality as compared to laparoscopic right colectomy, even after correction for confounding factors.

Laparoscopic conversion in colorectal cancer surgery; is there any improvement over time at a population level?

Conversion of laparoscopic colorectal cancer resection has been associated with worse outcome, but this might have been related to a learning curve effect. This study aimed to evaluate incidence, predictive factors and outcomes of laparoscopic conversion after the implementation phase of laparoscopic surgery at a population level. Patients undergoing elective resection of non-locally advanced, non-metastatic colorectal cancer between 2011 and 2015 were included. Data were extracted from the Dutch Surgical Colorectal Audit. Patients were grouped as laparoscopic completed (LR), laparoscopic converted (CONV) with further specification of timing (within or after 30 min) as registered in the DSCA, and open resection (OR). Uni- and multi-variate analyses were used to determine predictors of conversion and outcome (complicated course and mortality), with evaluation of trends over time. A total of 23,044 patients with colon cancer and 11,324 with rectal cancer were included. Between 2011 and 2015, use of laparoscopy increased from 55 to 84% in colon cancer, and from 49 to 89% in rectal cancer. Conversion rates decreased from 11.8 to 8.6% and from 13 to 8.0%, respectively. Laparoscopic hospital volume was independently associated with conversion rate. Only for colon cancer, the rate of complicated course was significantly higher after CONV compared to OR (adjusted odds ratio 1.486; 95% CI 1.298-1.702), and significantly higher after late (> 30 min) compared to early conversion (adjusted odds ratio 1.341; 1.046-1.719). There was no impact of CONV on mortality in both colon and rectal cancer. The use of laparoscopic colorectal cancer surgery increased to more than 80% at a national level, accompanied by a decrease in conversion which is significantly related to the laparoscopic hospital volume. Conversion was only associated with complicated course in colon cancer, especially when the reason for conversion consisted of an intra-operative complication, without affecting mortality.

The cost of conversion in robotic and laparoscopic colorectal surgery

BACKGROUND

Conversion from minimally invasive to open colorectal surgery remains common and costly. Robotic colorectal surgery is associated with lower rates of conversion than laparoscopy, but institutions and payers remain concerned about equipment and implementation costs. Recognizing that reimbursement reform and bundled payments expand perspectives on cost to include the entire surgical episode, we evaluated the role of minimally invasive conversion in total payments.

METHODS

This is an observational study from a linked data registry including clinical data from the Michigan Surgical Quality Collaborative and payment data from the Michigan Value Collaborative between July 2012 and April 2015. We evaluated colorectal resections initiated with open and minimally invasive approaches, and compared reported risk-adjusted and price-standardized 30-day episode payments and their components.

RESULTS

We identified 1061 open, 1604 laparoscopic, and 275 robotic colorectal resections. Adjusted episode payments were significantly higher for open operations than for minimally invasive procedures completed without conversion ($19,489 vs. $15,518, p < 0.001). The conversion rate was significantly higher with laparoscopic than robotic operations (15.1 vs. 7.6%, p < 0.001). Adjusted episode payments for minimally invasive operations converted to open were significantly higher than for those completed by minimally invasive approaches ($18,098 vs. $15,518, p < 0.001). Payments for operations completed robotically were greater than those completed laparoscopically ($16,949 vs. $15,250, p < 0.001), but the difference was substantially decreased when conversion to open cases was included ($16,939 vs. $15,699, p = 0.041).

CONCLUSION

Episode payments for open colorectal surgery exceed both laparoscopic and robotic minimally invasive options. Conversion to open surgery significantly increases the payments associated with minimally invasive colorectal surgery. Because conversion rates in robotic colorectal operations are half of those in laparoscopy, the excess expenditures attributable to robotics are attenuated by consideration of the cost of conversions.

Reduced 30-Day Mortality After Laparoscopic Colorectal Cancer Surgery: A Population Based Study From the Dutch Surgical Colorectal Audit (DSCA)

OBJECTIVES

To evaluate the impact of a laparoscopic resection on postoperative mortality after colorectal cancer surgery.

BACKGROUND

The question whether laparoscopic resection (LR) compared with open surgery [open resection (OR)] for colorectal cancer influences the risk of postoperative mortality remains unresolved. Several meta-analyses showed a trend but failed to reach statistical significance. The exclusion of high-risk patients and insufficient power might be responsible for that. We analyzed the influence of LR on postoperative mortality in a risk-stratified comparison and secondly, we studied the effect of LR on postoperative morbidity.

METHODS

Data from the Dutch Surgical Colorectal Audit (2010-2013) were used. Homogenous subgroups of patients were defined on the basis of factors influencing the choice of surgical approach and risk factors for postoperative mortality. Crude mortality rates were compared between LR and OR. The influence of LR on postoperative complications was evaluated using both univariable and multivariable analyses.

RESULTS

In patients undergoing elective surgery for nonlocally advanced, nonmetastasized colon cancer, LR was associated with a significant lower risk of postoperative mortality than OR in 20/22 subgroups. LR was independently associated with a lower risk of cardiac (odds ratio: 0.73, 95% confidence interval: 0.66-0.82) and respiratory (odds ratio: 0.73, 95% confidence interval: 0.64-0.84) complications.

CONCLUSIONS

LR reduces the risk of postoperative mortality compared with OR in elective setting in patients with nonlocally advanced, nonmetastasized colorectal cancer. Especially elderly frail patients seem to benefit because of reduced cardiopulmonary complications. These findings support widespread implementation of LR for colorectal cancer also in patients at high operative risk.

Comparison of inflammatory responses following robotic and open colorectal surgery: a prospective study

PURPOSE

Robotic colorectal surgery continues to rise in popularity, but there remains little evidence on the stress response following the procedure. The aim of this study was to evaluate the inflammatory response to robotic colorectal surgery and compare it with the response generated by open colorectal surgery.

METHODS

This was a prospective nonrandomized comparative study involving 61 patients with colorectal cancer. The evaluation of inflammatory response to either robotic or open colorectal surgery was expressed as changes in interleukin-1β, interleukin-1 receptor antagonist, interleukin-6, tumor necrosis factor-α, C-reactive protein, and procalcitonin during the first three postoperative days.

RESULTS

Of the 61 patients, 33 underwent robotic colorectal surgery while 28 had open colorectal surgery. Groups were comparable with respect to age, sex, BMI, cancer stage, and type of resection. The relative increase of interleukin-1 receptor antagonist at 8 h postoperative, compared to baseline, was higher in the open group (P = 0.006). The decrease of interleukin-1 receptor antagonist on postoperative days 1 and 3, compared to the maximum at 8 h, was more pronounced in the open group than in the robotic group (P = 0.008, P = 0.006, respectively), and the relative increase of interleukin-6 at 8 h after incision was higher in the open group (P = 0.007). The relative increase of procalcitonin on postoperative days 1 and 3 was higher in the open group than the robotic group (P < 0.001, P = 0.004, respectively).

CONCLUSIONS

This study shows that when compared with open colorectal surgery, robotic colorectal surgery results in a less pronounced inflammatory response and more pronounced anti-inflammatory action.

Single center cost analysis of single-port and conventional laparoscopic surgical treatment in colorectal malignant diseases

BACKGROUND AND PURPOSE

Single-port laparoscopy (SPL) is a relatively new technique, used in various procedures. There is limited knowledge about the cost effectiveness and the learning curve of this technique. The primary aim of this study was to compare hospital costs between SPL and conventional laparoscopic resections (CLR) for colorectal cancer; the secondary aim was to identify a learning curve of SPL.

METHODS

All elective colorectal cancer SPL and CLR performed in a major teaching hospital between 2011 and 2012 that were registered in the Dutch Surgical Colorectal Audit were included (n = 267). The economic evaluation was conducted from a hospital perspective, and costs were calculated using time-driven activity-based costing methodology up to 90 days after discharge. When looking at SPL only, the introduction year (2011) was compared to the next year (2012).

RESULTS

SPL (n = 78) was associated with lower mortality, lower reintervention rates, and more complications as compared to CLR (n = 189); however, none of these differences were statistically significant. A significant shorter operating time was seen in the SPL. Total costs were higher for SPL group as compared to CLR; however, this difference was not statistically significant. For the SPL group, most clinical outcomes improved between 2011 and 2012; moreover, total hospital costs for SPL in 2012 became comparable to CLR.

CONCLUSION

No significant differences in financial outcomes between SPL and CLR were identified. After the introduction period, SPL showed similar results as compared to CLR. Conclusions are based on a small single-port group and the conclusions of this manuscript should be an impetus for further research.

No Difference in Overall Survival Between Hospital Volumes for Patients With Colorectal Cancer in The Netherlands

BACKGROUND

High-volume hospitals have been associated with improved patient outcomes for tumors with a relatively low incidence that require complex surgeries, such as esophageal and pancreatic cancer. The volume-outcome association for colorectal cancer is under debate.

OBJECTIVE

This study investigated whether hospital volume for colorectal cancer is associated with surgical care characteristics and 5-year overall survival.

DESIGN

This is a population-based study.

SETTING

Data were gathered from the Netherlands Cancer Registry. Hospitals were grouped by volume for colon (<50, 50-74, 75-99, and ≥100 resections per year) and rectum (<20, 20-39, and ≥40 resections per year).

PATIENTS

All of the patients with primary nonmetastatic colorectal cancer who underwent resection between 2005 and 2012 were included.

MAIN OUTCOME MEASURES

Differences in surgical approach, anastomotic leakage, and postoperative 30-day mortality between hospital volumes were analyzed using χ tests and multivariable logistic regression analyses. Cox proportional hazard models were used to investigate the effect of hospital volume on overall survival.

RESULTS

This study included 61,394 patients with colorectal cancer. In 2012, 31 of the 91 hospitals performed less than 50 colon cancer resections per year, and 21 of the 90 hospitals performed less than 20 rectal cancer resections per year. No differences in anastomotic leakage rates between hospital volumes were observed. Only small differences between hospital volumes were revealed for conversion of laparoscopic to open resection (OR of less than 50 versus 100 or more resections per year = 1.25 (95% CI, 1.06-1.46)) and postoperative 30-day mortality (colon: OR of less than 50 versus 100 or more resections per year = 1.17 (95% CI, 1.02-1.35); rectum: OR of less than 20 versus 40 or more resections per year = 1.42 (95% CI, 1.09-1.84)). No differences in overall survival were found between hospital volumes.

LIMITATIONS

Although we adjusted for several patient and tumour characteristics, data regarding comorbidity, surgeon volume, local recurrences, and specific postoperative complications other than anastomotic leakage were not available.

CONCLUSIONS

In the Netherlands, no differences in 5-year survival rates were revealed between hospital volumes for patients with nonmetastatic colorectal cancer.

Imaging for Quality Control: Comparison of Systematic Video Recording to the Operative Note in Colorectal Cancer Surgery. A Pilot Study

Background

Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance.

Methods

From July 2015 through November 2015, patients aged ≥18 years undergoing elective colorectal cancer surgery were prospectively included in a single-institution trial. Video recording of key moments was performed peroperatively and analyzed for adequacy. The study cases were compared with a historic cohort. Video was compared with the operative note using the amount of adequate steps and a scoring system.

Results

This study compared 15 cases to 32 cases from the historic control group. Compared to the written operative note alone, significant differences in availability of information were seen in favor of video as well as using a combination of video plus the operative note (N adequate steps p = .024; p = <.001. Adequacy score: p = .039; p = <.001, both respectively).

Conclusions

Systematic video registration is feasible and seems to improve the availability of essential information after colorectal cancer surgery. In this respect, combining video with a traditional operative note would be the best option. A multicenter international study is being organized to further evaluate the effect of operative video capture on surgical outcomes.

High mortality rates after nonelective colon cancer resection: results of a national audit

AIM

Colon cancer resection in a nonelective setting is associated with high rates of morbidity and mortality. The aim of this retrospective study is to identify risk factors for overall mortality after colon cancer resection with a special focus on nonelective resection.

METHOD

Data were obtained from the Dutch Surgical Colorectal Audit. Patients undergoing colon cancer resection in the Netherlands between January 2009 and December 2013 were included. Patient, treatment and tumour factors were analysed in relation to the urgency of surgery. The primary outcome was 30-day postoperative mortality.

RESULTS

The study included 30 907 patients. A nonelective colon cancer resection was performed in 5934 (19.2%) patients. There was a 4.4% overall mortality rate, with significantly more deaths after nonelective surgery (8.5% vs 3.4%, P < 0.001). Older patients, male patients and patients with high comorbidity, advanced tumours, perforated tumours, a tumour in the right or transverse colon and postoperative anastomotic leakage were at risk of postoperative death. In nonelective resections, a right-sided tumour and postoperative anastomotic leakage were associated with high mortality.

CONCLUSION

Nonelective colon cancer resection is associated with high mortality. In particular, right-sided resections and patients with tumour perforation are at particularly high risk. The optimization of patients prior to surgery and expeditious operation after diagnosis might prevent the need for a nonelective resection.

Short-term outcomes after complete mesocolic excision compared with 'conventional' colonic cancer surgery

BACKGROUND

Complete mesocolic excision (CME) seems to be associated with improved oncological outcomes compared with 'conventional' surgery, but there is a potential for higher morbidity.

METHODS

Data for patients after elective resection at the four centres in the Capital Region of Denmark (June 2008 to December 2013) were retrieved from the Danish Colorectal Cancer Group database and medical charts. Approval from a Danish ethics committee was not required (retrospective study).

RESULTS

Some 529 patients who underwent CME surgery at one centre were compared with 1701 patients undergoing 'conventional' resection at the other three hospitals. Laparoscopic CME was performed in 258 (48·8 per cent) and laparoscopic 'conventional' resection in 1172 (68·9 per cent). More extended right colectomy procedures were done in the CME group (17·4 versus 3·6 per cent). The 90-day mortality rate in the CME group was 6·2 per cent versus 4·9 per cent in the 'conventional' group (P = 0·219), with a propensity score-adjusted logistic regression odds ratio (OR) of 1·22 (95 per cent c.i. 0·79 to 1·87). Laparoscopic surgery was associated with a lower risk of mortality at 90 days (OR 0·63, 0·42 to 0·95). Intraoperative injury to other organs was more common in CME operations (9·1 per cent versus 3·6 per cent for 'conventional' resection; P < 0·001), including more splenic (3·2 versus 1·2 per cent; P = 0·004) and superior mesenteric vein (1·7 versus 0·2 per cent; P < 0·001) injuries. Rates of sepsis with vasopressor requirement (6·6 versus 3·2 per cent; P = 0·001) and postoperative respiratory failure (8·1 versus 3·4 per cent; P < 0·001) were higher in the CME group.

CONCLUSION

CME is associated with more intraoperative organ injuries and severe non-surgical complications than 'conventional' resection for colonic cancer.

Clinical application of fast-track surgery with Chinese medicine treatment in the devascularization operation for cirrhotic portal hypertension

OBJECTIVE

To investigate the clinical effect of fast-track surgery combined with Chinese medicine treatment in devascularization operation for cirrhotic esophageal varices.

METHODS

Seventy-two patients with cirrhotic esophageal varices were selected from January 2009 to June 2013, and randomly assigned to a conventional group and a fast-track group (fast-track surgery combined with Chinese medicine treatment) using a randomized digital table, 36 cases in each group. Operation and anesthesia recovery time, postoperative hospitalization and quality of life were recorded and compared between groups during the perioperative period.

RESULTS

Compared with the conventional group, the fast-track group had longer operation time (253.6±46.4 min vs. 220.6±51.0 min) and anesthesia recovery time (50.5±15.9 min vs. 23.5±9.6 min; P<0.01); less bleeding (311.3±46.8 mL vs. 356.2±57.5 mL; P<0.01) and less transfusion (1932.3±106.9 mL vs. 2045.6±115.4 mL; P<0.01); as well as faster recovery of gastrointestinal function, shorter postoperative hospitalization and higher quality of life. There were no serious postoperative complications and no further bleeding occurred.

CONCLUSION

Fast-track surgery combined with Chinese medicine treatment is a safe and feasible approach to accelerate the recovery of patients with cirrhotic portal hypertension in perioperative period of devascularization operation.

Conversion during laparoscopic colorectal resections: a complication or a drawback? A systematic review and meta-analysis of short-term outcomes

PURPOSE

Several studies compared the outcomes of laparoscopically completed colorectal resections (LCR) to those requiring conversion to open surgery (COS). However, a comparative analysis between COS patients and patients undergoing planned open surgery (POS) would be useful to clarify if the conversion can be considered a simple drawback or a complication, being cause of additional postoperative morbidity. The aim of this study is to perform a meta-analysis of current evidences comparing postoperative outcomes of COS patients to POS patients.

METHODS

A systematic search of Medline, ISI Web of Knowledge, and Scopus was performed to identify studies reporting short-term outcomes of COS and POS patients. Primary outcomes were 30-day overall morbidity and length of postoperative hospital stay. Data were analyzed with fixed-effect modeling, and sensitivity analyses were performed to test the robustness of the results.

RESULTS

Twenty studies involving 30,656 patients undergoing POS and 1935 COS patients were selected. The mean conversion rate was 0.17. Similar 30-day overall morbidity and length of postoperative hospital stay were found in COS and POS patients. Wound infection (OR 1.43, 95 % CI 1.12 to 1.83, p < 0.01) was higher in the COS group. Other results were robust. Outcomes were comparable for patients undergoing resection for different natures of the disease (benign vs. malignant) and at different sites (colon vs. rectum).

CONCLUSION

Conversions from laparoscopic to open procedure during colorectal resection are not associated with a poorer postoperative outcome compared to patients undergoing planned open surgery, except for a higher risk of wound infection.

Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus

BACKGROUND AND OBJECTIVES

When deciding about the use of a defunctioning stoma in rectal cancer surgery, benefits and risks need to be weighed. This study investigated: (1a) factors associated with the use of defunctioning stomas; (1b) hospital variation; and (2) surgeons' perceptions regarding factors that determine this decision.

METHODS

Population-based data from the Dutch Surgical Colorectal Audit were used. Factors for receiving a defunctioning stoma were analyzed with multivariate logistic regression analysis. Hospital variation was assessed before and after case-mix adjustment. A survey was performed among gastroenterological surgeons on the importance of factors for the decision to construct a defunctioning stoma.

RESULTS

In total 4368 patients were analyzed and 103 (34%) surgeons participated. Male gender, higher body mass index, lower tumors, preoperative radiotherapy, and treatment in a teaching/university hospital increased the odds for a defunctioning stoma. Unadjusted hospital variation ranged from 0% to 98%. Variation remained after case-mix adjustment (0-100%). There was large variation in factors considered important for the decision; almost all factors were ranked as 'most important' at least once.

CONCLUSIONS

There is large variation in the use of defunctioning stomas for patients with rectal cancer, and a lack in uniformity of the selection criteria. These results underline the need to improve current decision making and identification of high-risk patients.