Evolution of laparoscopic colorectal surgery in Brazil: results of 4744 patients from the national registry. Surg Laparosc Endosc Percutan Tech. 2009;19:249-254. [PMID: 19542856 DOI: 10.1097/sle.0b013e3181a1193b]

An Overview of Robotic Colorectal Surgery Adoption and Training in Brazil

Background and Objectives: Robotic surgical systems have rapidly become integrated into colorectal surgery practice in recent years, particularly for rectal resections, where the advantages of robotic platforms over conventional laparoscopy are more pronounced. However, as with any technological advancement, the initial high costs can be a limiting factor, leading to unequal health service access, especially in middle- and lower-income countries. Materials and Method: A narrative review was conducted with the objective of providing an overview of the escalating adoption, current training programmes, and certification process of robotic colorectal surgery in Brazil. Results: Brazil has witnessed a rapid increase in robotic platforms in recent years. Currently, there are 106 robotic systems installed nationwide. However, approximately 60% of the medical facilities which adopted robotic platforms are in the Southeast region, which is both the most populous and economically prosperous in the country. The Brazilian Society of Coloproctology recently established clear rules for the training programme and certification of colorectal surgeons in robotic surgery. The key components of the training encompass theoretical content, virtual robotic simulation, observation, assistance, and supervised procedures in colorectal surgery. Although the training parameters are well established, no colorectal surgery residency programme in Brazil has yet integrated the teaching and training of robotic surgery into its curriculum. Thus far, the training process has been led by private institutions and the industry. Conclusion: Despite the fast spread of robotic platforms across Brazil, several challenges still need to be addressed to democratise training and promote the widespread use of these platforms. It is crucial to tackle these obstacles to achieve greater integration of robotic technology in colorectal surgery throughout the country.

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice

Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far.

Aim To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons.

Methods A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations.

Results 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don’t perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption.

Conclusions Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

Risk factors for prolonged length of stay after colorectal surgery

Objective Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery.

Design The study population included patients from the 2007 American-College-of-Sur- geons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS- NSQIP variables as predictive variables. P-value < 0.01 was considered significant.

Results 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were includ- ed. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, base- line sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract in- fection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery.

Conclusion Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric.

Laparoscopic training in colorectal surgery: can we do it safely?

Objective Laparoscopic approach should be offered for most patients requiring colectomy, as it is a safe procedure, associated with shorter hospitalization, better cosmetic results, and does not affect negatively the oncological outcomes of patients with colon cancer. However, there is no consistent data on the safety of laparoscopic surgery training during residency. Therefore, the aim of this study was to assess whether or not the resident par- ticipation in laparoscopic colectomy affected the postoperative outcomes.

Methods The database of the American College of Surgeons National Surgical Quality Im- provement Program (ACS-NSQIP) was searched for patients undergoing laparoscopic col- ectomies between 2005 and 2007. We excluded patients with no data regarding whether or not there was a resident participation in the operation. The study population was divided into 2 groups (resident and nonresident), according to residents participation in the surgi- cal procedure. Perioperative variables and postoperative complications were compared be- tween groups. A multivariate analysis was performed to evaluate the association between postoperative complications and resident participation in the operation.

Results The search yielded 5,912 patients with a median age of 63 years. Of these, 3,112 (53%) were female and 3.887 (66%) had a resident involved in their operation. The resident group had a significantly longer mean operative time (163 ± 64 min vs 138 ± 58 min, p < 0.0001). Other variables did not differ significantly between groups. Moreover, multivari- ate analysis showed no association between resident participation and the occurrence of postoperative complications.

Conclusion Laparoscopic training during residency may be safely performed without threatening the patient's integrity.

Systematic review of the use of big data to improve surgery in low- and middle-income countries

BACKGROUND

Technological advances have led to the generation of large amounts of data, both in surgical research and practice. Despite this, it is unclear how much originates in low- and middle-income countries (LMICs) and what barriers exist to the use of such data in improving surgical care. The aim of this review was to capture the extent and impact of programmes that use large volumes of patient data on surgical care in LMICs.

METHODS

A PRISMA-compliant systematic literature review of PubMed, Embase and Google Scholar was performed in August 2018. Prospective studies collecting large volumes of patient-level data within LMIC settings were included and evaluated qualitatively.

RESULTS

A total of 68 studies were included from 71 LMICs, involving 708 032 patients. The number of patients in included studies varied widely (from 335 to 428 346), with 25 reporting data on 3000 or more LMIC patients. Patient inclusion in large-data studies in LMICs has increased dramatically since 2015. Studies predominantly involved Brazil, China, India and Thailand, with low patient numbers from Africa and Latin America. Outcomes after surgery were commonly the focus (33 studies); very few large studies looked at access to surgical care or patient expenditure. The use of large data sets specifically to improve surgical outcomes in LMICs is currently limited.

CONCLUSION

Large volumes of data are becoming more common and provide a strong foundation for continuing investigation. Future studies should address questions more specific to surgery.

Short-term outcomes after laparoscopic colorectal surgery in patients with previous abdominal surgery: A systematic review

AIM: To perform a systematic review focusing on short-term outcomes after colorectal surgery in patients with previous abdominal open surgery (PAOS).

METHODS: A broad literature search was performed with the terms “colorectal”, “colectomy”, “PAOS”, “previous surgery” and “PAOS”. Studies were included if their topic was laparoscopic colorectal surgery in patients with PAOS, whether descriptive or comparative. Endpoints of interest were conversion rates, inadvertent enterotomy and morbidity. Analysis of articles was made according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS: From a total of 394 citations, 13 full-texts achieved selection criteria to be included in the study. Twelve of them compared patients with and without PAOS. All studies were retrospective and comparative and two were case-matched. The selected studies comprised a total of 5005 patients, 1865 with PAOS. Among the later, only 294 (16%) had history of a midline incision for previous gastrointestinal surgery. Conversion rates were significantly higher in 3 of 12 studies and inadvertent enterotomy during laparoscopy was more prevalent in 3 of 5 studies that disclosed this event. Morbidity was similar in the majority of studies. A quantitative analysis (meta-analysis) could not be performed due to heterogeneity of the studies.

CONCLUSION: Conversion rates were slightly higher in PAOS groups, although not statistical significant in most studies. History of PAOS did not implicate in higher morbidity rates.

Adequate lymphadenectomy for colorectal cancer: a comparative analysis between open and laparoscopic surgery

Background

In the surgical treatment of colorectal cancer, a lymphadenectomy is considered adequate when at least 12 lymph nodes are removed.

Aim

To evaluate whether videolaparoscopic surgery positively affects the rates of adequate lymphadenectomy.

Methods

An observational study was conducted with patients undergoing either open or videolaparoscopic surgery for colorectal cancer between 2008 and 2013. The following variables were collected: gender, age, tumor site, histology, degree of differentiation, tumor stage, number of lymph nodes removed, and number of lymph nodes affected by the disease.

Results

A total of 62 patients with colorectal cancer were included; 42 (67.7%) received open surgery, and 20 (32.3%) laparoscopic surgery. Regarding lymphadenectomy, a mean of 13 lymph nodes (95% CI: 10-16) were removed in the group that received open surgery, while 19 lymph nodes were removed (95% CI: 14-24) in the laparoscopic surgery group (p=0.021). Adequate lymphadenectomy (removal of at least 12 lymph nodes) was achieved in 58.1% of the total cases, in 50.0% of the patients who received open surgery, and in 75% of those who received laparoscopic surgery. Non-elderly patients and those with an advanced disease stage were more likely to receive an adequate lymphadenectomy (p=0.004 and p=0.035, respectively).

Conclusion

Disease stage and patient age were the factors that had the greatest influence on achieving an adequate lymphadenectomy. The type of surgery did not affect the number of lymph nodes removed.

Feasibility of emergency laparoscopic colectomy for children with acute colonic perforations and fibropurulent peritonitis

BACKGROUND

Several studies have demonstrated that laparoscopic surgery is safe and effective for urgent and emergent colectomy in adulthood. The aim of the present study was to evaluate the feasibility of laparoscopic colectomy for children in emergent settings.

METHODS

Between March 2008 and August 2011, 10 consecutive children with acute colonic perforations and fibropurulent peritonitis secondary to infectious colitis underwent emergency laparoscopic colectomy. Simultaneously, we reviewed and recorded the same data from another consecutive 10 patients who underwent standard laparotomy between November 2004 and February 2008. The two groups were compared with regard to operative time, length of hospital stay (LOS), and complications.

RESULTS

The gender, age, body weight, serum C-reactive protein, number of involved bowel segments, operative time, and LOS were not significantly different (P = 0.36, 0.50, 0.33, 0.62, 0.81, 0.14 and 0.23, respectively). In the laparoscopy group, one patient required conversion to open surgery because of extensive bowel involvement, and another patient with solitary colonic perforation required reoperation for anastomostic leakage. However, patients who underwent laparotomy had a higher incidence of later complications, including wound infection, incisional hernia, and adhesion ileus (P = 0.03, 0.06, and 0.03, respectively) and thus required more additional unplanned operations (P = 0.05).

CONCLUSIONS

Emergency laparoscopic surgery is technically feasible in most children with acute colonic perforations and fibropurulent peritonitis. However, extensive intestinal involvement with multiple perforations should be an indication for converting to open surgery.

Benefits of Laparoscopy: Does the Disease Condition that Indicated Colectomy Matter?

The benefits of laparoscopic (LC) over open colectomy (OC) have been well characterized for a variety of conditions. Whether the relative benefits of LC differ for different conditions has not been previously investigated. The aim of this study was to identify whether there are differences in benefits of LC for colon cancer (CC), Crohn's disease (CD), and diverticular disease (DD). Data of patients with CC, CD, and DD undergoing elective colectomy from January 2000 to December 2007 were identified from departmental databases. Patients with CC, CD, and DD undergoing LC were matched 1:1 for diagnosis, gender, body mass index, surgical procedure, American Society of Anesthesiologists scale, and date of surgery to patients undergoing OC. TNM stage was also matched for patients with CC. Two hundred eighty-nine patients undergoing LC (CC, 93; CD, 140; DD, 56) were matched 1:1 to 289 patients undergoing OC. Median age was 49 years (range, 14 to 91 years) in LC and 52 years (range, 14 to 98 years) in OC ( P = 0.35). All other matched criteria were also similar in both groups. The conversion rate to OC was 13 per cent (n = 36). Patients undergoing LC had significantly shorter lengths of stay (LOS) (3 days [range, 1 to 70 days] vs 6 days [range, 1 to 37 days], P < 0.001) and lower estimated blood loss (EBL) (100 mL [range, 10 to 1750 mL] vs 200 mL [range, 10 to 1700 mL], P < 0.001). Median operative time was similar in both groups (LC: 145 minutes [range, 35 to 431 minutes] vs OC: 135 minutes [range, 23 to 485 minutes], P = 0.54). The conversion rate was lower for DD (2%) when compared with CC (18.9%) and CD (13.4%). Improvement in EBL with LC was least pronounced in patients with CD and most pronounced in patients with DD ( P interaction < 0.001). In the LC group, patients with DD presented less postoperative complications ( P = 0.009). LC results in reduced LOS and EBL with similar complications rates when compared with OC. The benefits of LC are more pronounced in DD when compared with CD and CC.