Uptake and patient outcomes of laparoscopic colon and rectal cancer surgery in a publicly funded system and following financial incentives

Evaluating equity of access and predictors of minimally invasive hysterectomy for endometrial and cervical cancer from 2000 to 2017 in Ontario, Canada: A population-based cohort study

INTRODUCTION

We sought to assess the uptake of minimally invasive hysterectomy among patients with endometrial and cervical cancer in Ontario, Canada, and assess the equity of access to minimally invasive surgery (MIS) by evaluating associations with patient, disease, institutional, and provider factors.

METHODS

This is a retrospective population-based cohort study of hysterectomy for endometrial and cervical cancer in Ontario (2000-2017). Surgical approach, clinicopathologic, sociodemographic, institutional, and provider factors were identified through administrative databases. Fisher's exact, χ2 , Wilcoxon rank sum, logistic regression, and Cox proportional hazards modeling were used to explore factors associated with MIS.

RESULTS

A total of 27 652 patients were included. In total, 6199/24 264 (26%) endometrial and 842/3388 (25%) cervical cancer patients received MIS. The proportion of MIS to open surgeries increased from <0.1% in 2000 to over 55% in 2017 (odds ratio [OR] = 1.31, confidence interval [CI] = 1.28-1.34). Low-income quintile, rurality, low hospital volume, nonacademic hospital, nongynecologic oncology surgeon, and earlier year of surgeon graduation were associated with reduced odds of MIS (OR < 1).

CONCLUSIONS

The uptake of MIS hysterectomy increased steadily over the time period. Receipt of MIS is dependent upon multiple social determinants, provider variables, and systems factors. These disparities raise concern for health equity in Ontario and have significant implications for health systems planning and resource allocation.

Enthusiasm, Opinion Leaders, Comparative Advantage, and the Uptake Of Laparoscopic Resection For Colorectal Cancer Liver Metastases in Ontario, Canada: A Population-Based Cohort Study

BACKGROUND

Numerous factors likely influence adoption of surgical innovations in large regions. We considered the role of comparative advantage, surgeon enthusiasm, and opinion leaders on uptake of minimally invasive liver resection (MILR) for colorectal cancer (CRC) metastases in Ontario.

METHODS

We used administrative data for patients undergoing liver resection for CRC metastases from years 2006-2015. Fourteen regions were divided into three groups based on overall rate of MILR for CRC metastases. Outcomes included postoperative complications, length of hospital stay (LOS), operative mortality, and 1-year survival. We evaluated uptake of MILR among groups and within groups between opinion leader and nonopinion leader surgeons.

RESULTS

There were 2675 patients in the low-rate (n = 937), medium-rate (n = 919), and high-rate (n = 819) groups. In these same groups, the number of opinion leader surgeons was six, five, and six. Patient outcomes were similar among groups, except in the low-rate group LOS was 1 day greater (7 vs. 6 and 6; p = 0.017). The rate of MILR for CRC metastases did not change significantly among opinion leaders in any group. This rate among nonopinion leader surgeons was steady and low in the low-rate group (1.7-8.0%, p = 0.80) and increased in the mid-rate group (2.4-31.8%, p = 0.0026) and in the high-rate group (7.7-40.9%, p < 0.001).

CONCLUSIONS

Greater use of MILR was associated with a 1-day shorter LOS. Relative enthusiasm for MILR for CRC metastases among a small number of opinion leader surgeons likely facilitated or dampened uptake of this complex innovation.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery

Purpose

In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing.

Methods

A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients’ characteristics, outcomes, and complications were collected retrospectively.

Results

The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients.

Conclusion

Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Simultaneous resection of colorectal cancer with synchronous liver metastases; a practice survey

BACKGROUND

We examined surgeon practice intentions and barriers to performing simultaneous resections for colorectal cancer with synchronous liver metastases.

METHODS

We electronically surveyed North American surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Four clinical scenarios of increasing complexity were presented. Perceived outcomes of and barriers to simultaneous resection were assessed on a 7-point Likert scale. We compared results between general and hepatobiliary surgeons.

RESULTS

Responses (rate 20%, 234/1166) included 50 general and 134 hepatobiliary surgeons. High likelihood scores for support of simultaneous resection among general and hepatobiliary surgeons, respectively, included the following for: minor liver and low complexity colon, 83% and 98% (p < 0.001); minor liver and rectal resection, 57% and 73% (p = 0.042); complex liver and low complexity colon resection, 26% and 24% (p = 0.858); and, complex liver and rectal resection, 11% and 7.0% (p = 0.436). Among hepatobiliary surgeons, the most common barriers to simultaneous resections were patient comorbidities and lung metastases, whereas certain general surgeons additionally identified transfer of care.

CONCLUSIONS

Surgeon support for simultaneous resection was high for cases with minor hepatectomy, and low for cases involving major hepatectomy. These results suggest that clinical trials should involve patients with limited disease to evaluate post-operative complications and cost.

Do Diagnostic and Procedure Codes Within Population-Based, Administrative Datasets Accurately Identify Patients with Rectal Cancer?

BACKGROUND

Procedural and diagnostic codes may inaccurately identify specific patient populations within administrative datasets.

PURPOSE

Measure the accuracy of previously used coding algorithms using administrative data to identify patients with rectal cancer resections (RCR).

METHODS

Using a previously published coding algorithm, we re-created a RCR cohort within administrative databases, limiting the search to a single institution. The accuracy of this cohort was determined against a gold standard reference population. A systematic review of the literature was then performed to identify studies that use similar coding methods to identify RCR cohorts and whether or not they comment on accuracy.

RESULTS

Over the course of the study period, there were 664,075 hospitalizations at our institution. Previously used coding algorithms identified 1131 RCRs (administrative data incidence 1.70 per 1000 hospitalizations). The gold standard reference population was 821 RCR over the same period (1.24 per 1000 hospitalizations). Administrative data methods yielded a RCR cohort of moderate accuracy (sensitivity 89.5%, specificity 99.9%) and poor positive predictive value (64.9%). Literature search identified 18 studies that utilized similar coding methods to derive a RCR cohort. Only 1/18 (5.6%) reported on the accuracy of their study cohort.

CONCLUSIONS

The use of diagnostic and procedure codes to identify RCR within administrative datasets may be subject to misclassification bias because of low PPV. This underscores the importance of reporting on the accuracy of RCR cohorts derived within population-based datasets.

A Comparison of Pathologic Outcomes of Open, Laparoscopic, and Robotic Resections for Rectal Cancer Using the ACS-NSQIP Proctectomy-Targeted Database: a Propensity Score Analysis

BACKGROUND

There is ongoing debate regarding the benefits of minimally invasive techniques for rectal cancer surgery. The aim of this study was to compare pathologic outcomes of patients who underwent rectal cancer resection by open surgery, laparoscopy, and robotic surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) proctectomy-targeted database.

METHODS

All patients from the 2016 ACS-NSQIP proctectomy-targeted database who underwent elective proctectomy for rectal cancer were identified. Patients were divided into three groups based on initial operative approach: open surgery, laparoscopy, and robotic surgery. Pathologic and 30-day clinical outcomes were then compared between the groups. A propensity score analysis was performed to control for confounders, and adjusted odds ratios for pathologic outcomes were reported.

RESULTS

A total of 578 patients were included-211 (36.5%) in the open group, 213 (36.9%) in the laparoscopic group, and 154 (26.6%) in the robotic group. Conversion to open surgery was more common among laparoscopic cases compared to robotic cases (15.0% vs. 6.5%, respectively; p = 0.011). Positive circumferential resection margin (CRM) was observed in 4.7%, 3.8%, and 5.2% (p = 0.79) of open, laparoscopic, and robotic resections, respectively. Propensity score adjusted odds ratios for positive CRM (open surgery as a reference group) were 0.70 (0.26-1.85, p = 0.47) for laparoscopy and 1.03 (0.39-2.70, p = 0.96) for robotic surgery.

CONCLUSIONS

The use of minimally invasive surgical techniques for rectal cancer surgery does not appear to confer worse pathologic outcomes.

Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want?

BACKGROUND

Colorectal surgery outcomes must be accurately assessed and aligned with patient priorities. No study to date has investigated the patient's subjective assessment of outcomes most important to them during and following their surgical recovery. Although surgeons greatly value the benefits of laparoscopy, patient priorities remain understudied.

OBJECTIVE

This study aimed to assess what aspects of patients' perioperative care and recovery they value most when queried in the postoperative period.

DESIGN

This study is an exploratory cross-sectional investigation of a defined retrospective patient population. Enrollees were stratified into subcategories and analyzed, with statistical analysis performed via χ test and unpaired t test.

SETTINGS

This study was conducted at a single academic medical center in New England.

PATIENTS

Patients who underwent a colorectal surgical resection between 2009 and 2015 were selected.

INTERVENTIONS

Patients within a preidentified population were asked to voluntarily complete a 32-item questionnaire regarding their surgical care.

MAIN OUTCOME MEASURES

The primary outcomes measured were patient perioperative and postoperative quality of life and satisfaction on selected areas of functioning.

RESULTS

Of 167 queried respondents, 92.2% were satisfied with their recovery. Factors considered most important included being cured of colorectal cancer (76%), not having a permanent stoma (78%), and avoiding complications (74%). Least important included length of stay (13%), utilization of laparoscopy (14%), and incision appearance and length (2%, 4%).

LIMITATIONS

The study had a relatively low response rate, the study is susceptible to responder's bias, and there is temporal variability from surgery to questionnaire within the patient population.

CONCLUSIONS

Overall, patients reported high satisfaction with their care. Most important priorities included being free of cancer, stoma, and surgical complications. In contrast, outcomes traditionally important to surgeons such as laparoscopy, incision appearance, and length of stay were deemed less important. This research helps elucidate the outcomes patients truly consider valuable, and surgeons should focus on these outcomes when making surgical decisions. See Video Abstract at http://links.lww.com/DCR/A596. See Visual Abstract at https://tinyurl.com/yb25xl66.

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.

Robotic surgery for rectal cancer: the future?

Robotic technology currently offers some technical advantages in pelvic dissection compared with competing minimally invasive techniques, and adoption for the surgical treatment of rectal cancer is rapidly increasing worldwide. While there are some early data demonstrating modest improvement in patient outcomes, benefits in terms of long-term oncological outcomes, as well as potential improvements in surgeon-centered outcomes such as fatigue and repetitive stress injury are actively being investigated. Rapid innovation, with the impending release of several new robotic platforms, is likely to further expand the application of these technologies, improve on current limitations, and reduce capital and consumable costs. It is imperative that, as the technology develops and adoption increases further, clinician and research led programs drive safe implementation with a patient-first approach.

Outcomes following laparoscopic rectal cancer resection by supervised trainees

Background

The aim was to evaluate the applicability of laparoscopic surgery in the treatment of primary rectal cancer in a training unit.

Methods

A cohort analysis was undertaken of consecutive patients undergoing elective surgery for primary rectal cancer over a 7-year interval. Data on patient and operative details, and short-term clinicopathological outcomes were collected prospectively and analysed on an intention-to-treat basis.

Results

A total of 306 patients (213 men, 69·6 per cent) of median (i.q.r.) age 67 (58–73) years with a median body mass index of 26·6 (23·9–29·9) kg/m2 underwent surgery. Median tumour height was 8 (6–11) cm from the anal verge, and 46 patients (15·0 per cent) received neoadjuvant radiotherapy. Seven patients (2·3 per cent) were considered unsuitable for laparoscopic surgery and underwent open resection; 299 patients (97·7 per cent) were suitable for laparoscopic surgery, but eight were randomized to open surgery as part of an ongoing trial. Some 291 patients (95·1 per cent) underwent a laparoscopic procedure, with conversion required in 29 (10·0 per cent). Surgery was partially or completely performed by trainees in 72·4 per cent of National Health Service patients (184 of 254), whereas private patients underwent surgery primarily by consultants. Median postoperative length of stay for all patients was 6 days and the positive circumferential resection margin rate was 4·9 per cent (15 of 306).

Conclusion

Supervised trainees can perform routine laparoscopic rectal cancer resection.

Preoperative endoscopy localization error rate in patients with colorectal cancer

BACKGROUND

Preoperative repeat endoscopy in colorectal cancer (CRC) patients is considered by many to be an integral component of surgical planning. Little is known, however, about the utility of re-endoscopy.

METHODS

A retrospective review of 342 consecutive patients undergoing elective surgical resection for CRC from January 2008 to December 2011 was performed. Patients were included if the initial endoscopist was different than the operating surgeon. A localization error was recorded if the final tumor location identified during surgery was in a different anatomical segment than that identified by endoscopy. The Chi-squared test was used to compare categorical variables. An error rate with a 95% confidence interval was obtained using the exact binomial distribution.

RESULTS

298 patients were identified, 118 (39.6%) of whom also underwent a preoperative re-endoscopy by the operating surgeon or partner. Nineteen patients had incorrect tumor localization at initial endoscopy, equivalent to a 6.4% error rate (95% CI 3.88-9.78). In comparison, there were two localization errors on re-endoscopy, 1.69% (95% CI 0.21-6.00). Re-endoscopy was found to be protective against localization errors (P < 0.05), correcting 10 of the 12 errors made at the initial endoscopy. The sensitivity of re-endoscopy as a diagnostic tool to detect errors was 83% with a corresponding specificity of 100%. The overall accuracy of re-endoscopy in preventing endoscopic localization errors was 92% (95% CI 81-100).

CONCLUSIONS

There is a small but important localization error rate in preoperative endoscopic evaluation of colorectal tumors. Re-endoscopy appears to be safe and may potentially identify and correct these errors and help with preoperative planning at the expense of delaying surgery. Further research is necessary to find ways to improve localization and identify which patients would benefit from re-endoscopy.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

BACKGROUND

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis.

OBJECTIVE

The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes.

DESIGN

This is a population-based retrospective cohort study using administrative discharge data.

SETTING

This study was conducted in Ontario, Canada.

PATIENTS

All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012).

MAIN OUTCOME MEASURES

Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics.

RESULTS

There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001).

LIMITATIONS

There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data.

CONCLUSIONS

There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.