Laparoscopic Colectomy Decreases the Time to Administration of Chemotherapy Compared with Open Colectomy

Attitudes of physicians and patients toward immediate and intraoperative chemotherapy treatment in colon cancer

INTRODUCTION

We have shown in a Phase I trial that immediate adjuvant chemotherapy (IAC) during surgical resection and immediately postoperative is safe and feasible in patients with colon cancer (CC). IAC avoids delays in adjuvant treatment and has the potential to improve survival and quality of life. We aim to determine patients and providers attitudes toward this novel multidisciplinary treatment approach.

METHODS

Two web-based surveys were administered to newly diagnosed CC patients, survivors, surgeons and oncologists. Surveys assessed treatment preferences and perceived barriers to IAC. Chi-square tests were conducted to compare differences between patients' and providers' responses.

RESULTS

Responses were collected from 35 patients and 40 providers. Patients were more willing to: (1) proceed with IAC to finish treatment earlier thus possibly improving quality of life (p = 0.001); (2) proceed with IAC despite potential side effects (p < 0.001); and (3) proceed with a dose of intraoperative chemotherapy even if on final pathology, may not have been needed (p = 0.002). Patients were more likely to indicate no barriers to collaborative care (p = 0.001) while providers were more likely to cite that it is time consuming, thus a barrier to participation (p = 0.001), has scheduling challenges (p = 0.001), and physicians are not available to participate (p = 0.003).

CONCLUSIONS

We observed a discordance between what providers and patients value in perioperative and adjuvant CC treatment. Patients are willing to accept IAC despite potential side effects and without survival benefit, highlighting the importance of understanding patient preference.

Keep Them on the Table: Outcomes Are Improved After Minimally Invasive Colectomy Despite Longer Operative Times in Patients With High-Risk Colon Cancer

BACKGROUND

For high-risk patients, traditional surgical dogma advises open operations, with short operative times, to "get them off the table" instead of longer minimally invasive surgery approaches.

OBJECTIVE

The aim of this study was to compare postoperative outcomes in patients with high-risk colon cancer undergoing elective longer minimally invasive surgery operations compared with shorter open operations.

DESIGN

Retrospective comparative cohort study.

SETTINGS

Interventions were performed in hospitals participating in the national surgical database.

PATIENTS

The National Surgical Quality Improvement Program database was used to identify patients with colon cancer with ASA class 3 to 4 undergoing right and sigmoid colectomy between 2012 and 2017.

MAIN OUTCOME MEASURES

Thirty-day postoperative outcomes were compared between short open and long minimally invasive groups.

RESULTS

A total of 3775 patients were identified as having undergone long minimally invasive right colectomy and short open right colectomy (33% open, 67% minimally invasive surgery), and 1042 patients were identified as having undergone long minimally invasive sigmoid colectomy and short open sigmoid colectomy (36% open, 64% minimally invasive). Patients undergoing long minimally invasive right colectomy had significantly lower rates of overall morbidity, severe adverse events, mortality, superficial surgical site infections, and wound disruptions, as well as discharge to a higher level of care and shorter length of stay ( p < 0.05). Patients undergoing long minimally invasive sigmoid colectomy had decreased rates of overall morbidity, severe adverse events, and length of stay, as well as discharge to a higher level of care compared with the patients undergoing short open sigmoid colectomy ( p < 0.05).

LIMITATIONS

This study was limited by the retrospective nature and standardized outcome measures.

CONCLUSIONS

In high-risk patients undergoing colectomy for colon cancer, outcomes were worse with shorter open compared with longer minimally invasive surgery operations. Focus should shift from getting patients "off the table" faster to longer, but safer, minimally invasive surgery in high-risk patients. See Video Abstract at http://links.lww.com/DCR/B642 .

MANTNGALOS SOBRE LA MESA HAY MEJORES RESULTADOS DESPUS DE COLECTOMA MNIMAMENTE INVASIVA A PESAR DE TIEMPOS QUIRRGICOS MS PROLONGADOS EN PACIENTES CON CNCER DE COLON DE ALTO RIESGO

ANTECEDENTES:Para los pacientes de alto riesgo, el dogma quirúrgico tradicional aconseja operaciones abiertas, con tiempos quirúrgicos cortos, con el fin de "sacarlos de la mesa" en lugar de enfoques quirúrgicos mínimamente invasivos más prolongados.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios en pacientes electivos de cáncer de colon de alto riesgo sometidos a operaciones de cirugía mínimamente invasiva más prolongadas en comparación con operaciones abiertas más cortas.DISEÑO:Los resultados posoperatorios de pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha o sigmoidea se compararon en un análisis multivariado. Se comparó el grupo de colectomía derecha abierta corta (tiempo operatorio <116 minutos) y colectomía derecha mínimamente invasiva larga (tiempo operatorio> 132 minutos). También se compararon la colectomía sigmoidea abierta corta (tiempo operatorio <127 minutos) y la colectomía sigmoidea mínimamente invasiva larga (tiempo operatorio> 161 minutos).ESCENARIO:Las intervenciones se realizaron en hospitales participantes en la base de datos quirúrgica nacional.PACIENTES:La base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica se utilizó para identificar a los pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha y sigmoidea entre 2012-2017.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados posoperatorios a los treinta días entre el grupo de procedimientos abiertos cortos y el de mínimamente invasivos largos.RESULTADOS:Se identificó un total de 3.775 pacientes sometidos a colectomía derecha mínimamente invasiva larga y colectomía derecha abierta corta (33% abierta, 67% cirugía mínimamente invasiva) y se identificaron 1042 pacientes sometidos a colectomía sigmoidea mínimamente invasiva larga y colectomía sigmoidea abierta corta (36% abierta, 64% mínimamente invasiva). Los pacientes con colectomía derecha larga mínimamente invasiva tuvieron significativamente menor morbilidad general, eventos adversos graves, mortalidad, infecciones superficiales del sitio quirúrgico, dehiscencia de herida, alta a un nivel más alto de atención y estadía más corta ( p <0.05). Los pacientes con colectomía sigmoidea mínimamente invasiva prolongada tuvieron menor morbilidad general, eventos adversos graves, duración de la estadía y alta a un nivel más alto de atención en comparación con los pacientes con colectomía sigmoidea abierta corta ( p <0.05).LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva y las medidas de resultado estandarizadas.CONCLUSIONES:En los pacientes de alto riesgo sometidos a colectomía por cáncer de colon, los resultados fueron peores con operaciones abiertas más cortas en comparación con operaciones mínimamente invasivas más largas. El enfoque debe pasar de hacer que los pacientes "salgan rápido de la mesa quirúrgica" a una cirugía mínimamente invasiva más prolongada pero más segura, en pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B642 . (Traducción-Dr. Jorge Silva Velazco ).

The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study

BACKGROUND

Bariatric surgery has relatively low complication rates, especially severe postoperative complications (defined by Clavien-Dindo classification as types 3 and 4), but these rates cannot be ignored. In other than bariatric surgical disciplines, complications affect not only short-term but also long-term results. In the field of bariatric surgery, this topic has not been extensively studied.

OBJECTIVES

The aim of the study was to assess the outcomes of bariatric treatment in patients with obesity and severe postoperative complications in comparison to patients with a noneventful perioperative course.

SETTING

Six surgical units at Polish public hospitals.

METHODS

We performed a multicenter propensity score matched analysis of 206 patients from 6 Polish surgical units and assessed the outcomes of bariatric procedures. A total of 103 patients with severe postoperative complications (70 laparoscopic sleeve gastrectomy [SG] and 33 with laparoscopic Roux en Y gastric bypass [RYGB]) were compared to 103 patients with no severe complications in terms of peri- and postoperative outcomes.

RESULTS

The outcomes of bariatric treatment did not differ between compared groups. Median percentage of total weight loss 12 months after the surgery was 28.8% in the group with complications and 27.9% in patients with no severe complications (P = 0.993). Remission rates of both type 2 diabetes mellitus and arterial hypertension showed no significant difference between SG and RYGB (36% versus 42%, P = 0.927, and 41% versus 46%, P = 0.575. respectively).

CONCLUSIONS

The study suggests that severe postoperative complications had no significant influence either on weight loss effects or obesity-related diseases remission.

A comparison of minimally invasive vs open distal pancreatectomy for resectable pancreatic ductal adenocarcinoma: Propensity score matching analysis

BACKGROUND

Owing to concerns regarding adequate oncological outcomes and perioperative complications, minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) has limited generalizability. The aim of this study was to assess the perioperative and oncologic outcomes of MIDP compared with open distal pancreatectomy (ODP) for resectable PDAC after propensity score matching (PSM).

METHODS

The patients who underwent MIDP and ODP for PDAC between January 2010 and December 2017 were retrospectively reviewed. Demographics, perioperative outcomes, pathological outcomes, and overall and disease-free survival data were collected to compare MIDP and ODP. After PSM, perioperative and oncologic outcomes were analyzed.

RESULTS

A total of 156 MIDP patients were compared with 156 ODP patients for resectable PDAC after PSM. Tumor size, TNM stage, differentiation, harvested lymph nodes, and positive lymph nodes were not different except for R1 resection and lymphovascular invasion between the MIDP and ODP groups. Operation times, overall complications, POPF, and adjuvant treatment were also not different between the two groups. The MIDP group had shorter hospital stays (10.0 vs 13.4 days, P < 0.001) and shorter interval times from surgery to adjuvant treatment (37.6 days vs 46.0 days, P = 0.002) than the ODP group. The MIDP group had better overall survival (34.9 vs 24.5 months, P = 0.012) and disease-free survival (16.2 vs 10.3 months, P = 0.001).

CONCLUSION

Minimally invasive distal pancreatectomy has advantages with respect to postoperative hospital stay, interval between surgery, and adjuvant treatment. MIDP is associated with the possibility of improved survival rate for resectable PDAC.

Laparoscopic multivisceral resection for locally advanced colon cancer: a single-center analysis of short- and long-term outcomes

PURPOSE

We evaluated the technical and oncological safety of laparoscopic multivisceral resection (MVR) in selected patients with locally advanced colon cancer (LACC).

METHODS

We compared the clinical backgrounds, and short- and long-term outcomes of patients who underwent laparoscopic vs. those who underwent open MVR for LACC en bloc at our hospital.

RESULTS

Between January, 2004 and December, 2015, 140 patients underwent MVR of the primary tumor en bloc via laparoscopic surgery (laparoscopic group; LG, n = 69) or open surgery (open group; OG, n = 71). Laparoscopic surgery was selected mainly for tumors that invaded the bladder and abdominal wall. The LG patients had smaller tumors (60 vs. 80 mm, p < 0.001), less blood loss (30 vs. 181 g, p < 0.001), and shorter hospital stays (12 vs. 19 days, p < 0.001) than the OG patients. Open conversion was required for two patients. Postoperative complications and R0 resection were comparable between the groups. Local recurrence occurred in two LG patients and two OG patients. The 5-year cancer-specific survival, disease-free survival, and local disease-free survival of patients with pT4b disease were not significantly different between the LG and OG groups (90.3% vs. 75.2%, 71.2% vs. 67.6%, and 97.1% vs. 94.2%).

CONCLUSION

Although the LG included patients with lower risk, the short- and long-term outcomes were equivalent to those of the OG, which included patients with higher risk.

Safety and feasibility of in-hospital early chemotherapy initiation after surgery in patients with stage II-IV colon cancer

Although it is recommended to initiate postoperative chemotherapy for colon cancer within 8 weeks after surgery, the feasibility and impact of initiating chemotherapy before discharge after surgical resection has not been investigated.Patients with stage II-IV colon cancer who received postoperative chemotherapy were dichotomized into early (chemotherapy initiation before discharge) and control (chemotherapy initiation after discharge) groups. A multivariable logistic regression model was used to determine factors associated with delayed chemotherapy, defined as more than 6 or 8 weeks after surgery.From January 2004 to December 2012, of 729 patients with stage II-IV colon adenocarcinoma, 555 patients (76.1%) underwent postoperative chemotherapy. Of them, 181 (32.6%) patients were included in the early group. Time to initiation of chemotherapy was significantly shorter in the early group than in the control group (14.9 days vs 31.5 days, P < . 001). Multivariate analysis revealed that tumor stage and chemotherapy initiation strategy (odds ratio 8.4; 95% confidence interval, 1-66, P = .041) were independent predictors of delayed initiation of chemotherapy at more than 8 weeks. There was no difference in the completion rate of planned chemotherapy cycles between the 2 groups (P > .05).The strategy of initiating chemotherapy before discharge after surgery is safe and feasible and might reduce the potential delay in chemotherapy initiation in patients with colon cancer.

Postoperative complications are associated with worse survival after laparoscopic surgery for non-metastatic colorectal cancer - interim analysis of 3-year overall survival

Introduction

Postoperative morbidity after colorectal resections for cancer remains a significant problem. Data on the influence of complications on survival after laparoscopic colorectal resection are still limited.

Aim

To analyze the impact of postoperative complications on long-term survival after radical laparoscopic resection for colorectal cancer.

Material and methods

Two hundred and sixty-five consecutive non-metastatic colorectal cancer patients undergoing laparoscopic colorectal resection for cancer were included in the analysis. The entire study group was divided into two subgroups based on the occurrence of postoperative complications. Group 1 included patients without postoperative morbidity and group 2 included patients with complications. The primary outcome was overall survival.

Results

Median follow-up was 45 (IQR: 34–55) months. Group 1 consisted of 187 (70.5%) patients and group 2 comprised 78 (29.5%) patients. Studied groups were comparable in terms of sex, age, body mass index, ASA class, cancer staging, localization of the tumor and operative time. Patients in group 1 had significantly better overall 3-year survival compared to those with complications (84.9% vs. 69.8%, p = 0.022). Kaplan-Meier curves showed significantly improved survival rates in patients without complications compared with complicated cases. The Cox proportional multivariate model showed that postoperative complications (HR = 2.83; 95% CI: 1.35–5.92; p = 0.0058) and AJCC III (HR = 3.17; 95% CI: 1.52–6.6; p = 0.0021) were independent predictors of worse survival after laparoscopic colorectal cancer surgery.

Conclusions

Our analysis of interim results after 3 years confirms that complications after laparoscopic colorectal cancer surgery have an impact on survival. For this reason, these patients should be carefully monitored after surgery aiming at early detection of recurrence.

Delivery of adjuvant chemotherapy among stage III colon cancer patients at a public versus private hospital in New York City

PURPOSE

Prior studies of timeliness of adjuvant chemotherapy (AC) initiation in stage III colon cancer have suggested longer time to AC at public compared with private hospitals. Few studies have explored differences in AC completion. We investigated whether timely initiation and completion of AC differed between a public and private hospital, affiliated with the same academic institution in a large, urban setting.

METHODS

We conducted a retrospective cohort study of stage III colon cancer patients who had surgery and AC at the same medical center between 2008 and 2015, either at its affiliated public hospital (n = 43) or private hospital (n = 79). We defined timely initiation as receiving AC within 60 days postoperatively, and completion as receiving ≥ 75% of planned AC. Univariate and stepwise multivariable logistic regressions were used to identify factors associated with AC delivery.

RESULTS

Median number of days to AC was significantly greater among patients at the public (53, range 31-231) compared with the private hospital (43, range 25-105; p = 0.002). However, the percentage of patients with timely AC initiation did not differ substantially by hospital (74 vs 81%, p = 0.40). In multivariable analysis, age (OR 0.95/year, 95% CI 0.91-0.99) and laparoscopic versus open surgery (OR 5.65, 95% CI 1.92-16.62) were significant factors associated with timely AC initiation. Moreover, AC completion did not differ significantly between public (83.7%) and private (89.9%) hospital patients (p = 0.32).

CONCLUSIONS

The proportions of patients with timely initiation and completion of AC were similar at a public and private hospital affiliated with a large, urban medical center. Future research should investigate how specific system-level factors help alleviate this expected difference in timely care delivery.

The Relationship Between Clavien-Dindo Morbidity Classification and Oncologic Outcomes After Colorectal Cancer Resection

BACKGROUND

Limited data on the relationship between postoperative complications (POCs) after colorectal cancer resection and oncologic outcomes are available. We hypothesized that the increased severity of POCs is associated with progressively worse oncologic outcomes.

METHODS

Patients with pathological stages I-III colorectal adenocarcinoma undergoing elective curative resection in a single institution between 2000 and 2012 were identified from a prospectively collected database. The severity of POCs was determined using the Clavien-Dindo classification, and oncologic outcomes were assessed.

RESULTS

Of 2266 patients, 669 (30%) had at least one POC. POCs were not associated with pathologic stage (p = 0.58) or use of adjuvant therapy (p = 0.19). With a mean follow-up of 5.3 years, POCs were associated with decreased 5-year overall survival (OS) (60% vs. 77%, p < 0.001), disease-free survival (DFS) (53% vs. 70%, p < 0.001), cancer-specific survival (CSS) (81% vs. 87%, p < 0.001), and increased overall recurrence rates (19% vs. 15%, p = 0.008). Increasing Clavien-Dindo scores from I to IV was significantly associated with progressively decreasing OS (71, 64, 60, 22%, p < 0.001), DFS (65, 58, 51, 19%, p < 0.001), CSS (88, 77, 79, 74%, p < 0.001), and increasing recurrence rates (12, 20, 26, 18%, p = 0.002). Multivariate analysis confirmed POCs as an independent factor associated with decreased OS [hazard ratio (HR) 0.63, 95% CI 0.52-0.76], DFS (HR 0.64, 95% CI 0.54-0.76), CSS (HR 0.73, 95% CI 0.56-0.97), and increased recurrence rates (HR 1.36, 95% CI 1.02-1.80).

CONCLUSIONS

POCs are associated with adverse oncologic outcomes, with increasing effect with higher Clavien-Dindo score. Efforts to reduce both the incidence and severity of complications should result in improved oncologic outcomes.

Factors Influencing Difficulty of Laparoscopic Abdominoperineal Resection for Ultra-Low Rectal Cancer

PURPOSE

Our current study was conducted to identify patients' anatomic, pathologic, and clinical factors to predict difficulty of performing laparoscopic abdominoperineal resection for ultra-low rectal cancer.

MATERIALS AND METHODS

Records of 117 consecutive patients with rectal cancer 2 to 5 cm from the anal verge were retrospectively reviewed. Using univariate and multivariate linear or logistic regression models, standardized operative time and blood loss, as well as postoperative morbidity were utilized as endpoints to screen patients' multiple variables to predict operative difficulty.

RESULTS

Multivariate linear regression analysis showed body mass index (BMI) (estimate=0.07, P=0.0056), interspinous distance (estimate=-0.02, P=0.0011), tumor distance from anal verge (estimate=-0.17, P=0.0355), prior abdominal surgery (estimate=0.51, P=0.0180), preoperative chemoradiotherapy (estimate=0.67, P=0.0146), and concurrent diseases (hypertension and/or diabetes mellitus) (estimate=0.49, P=0.0122) are predictors for standardized operative time. Age (estimate=0.02, P=0.0208) and concurrent diseases (estimate=0.43, P=0.0476) were factors related to standardized blood loss. BMI (estimate=0.15, P=0.0472) was the only predictor for postoperative morbidity based on logistic regression analysis.

CONCLUSIONS

Age, BMI, interspinous distance, tumor distance from anal verge, prior abdominal surgery, preoperative chemoradiotherapy, and concurrent diseases influence the difficulty of performing laparoscopic abdominoperineal resection for ultra-low rectal cancer. Standardized operative time allows researchers to amass samples by pooling data from all published studies, thus building reliable models to predict operative difficulty for clinical use.

Cost comparison of laparoscopic colectomy versus open colectomy in colon cancer

BACKGROUND

Laparoscopic colectomy has been shown to be safe, oncologically comparable, and clinically beneficial over open colectomy for colon cancer, but utilization remains low. Objectives To evaluate the cost of laparoscopic colectomy vs open colectomy for colon cancer.

METHODS

The authors conducted a retrospective claims data analysis using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The denominator population consisted of individuals who had commercial insurance coverage in all months of 2012 and >1 month in 2013 and pharmacy coverage throughout eligibility. The study population included individuals aged 18-64 years who were identified with colon cancer in 2013 and underwent an elective inpatient open colectomy or laparoscopic colectomy between January and November 2013. The cost and re-admission rate of open vs laparoscopic colectomy were compared after risk, adjusting for comorbidities, demographics, and geographic region.

RESULTS

During the study period, 1299 elective inpatient colon cancer colectomies were performed (open, n = 558; laparoscopic, n = 741). After risk adjustment, the laparoscopic vs open group was shown to have lower re-admission rates (6.61 and 10.93 per 100 cases, respectively, p = .0165), lower average re-admission costs ($1676 and $3151, respectively, p = .0309), and lower 30-day post-discharge healthcare utilization costs ($4842 and $7121, respectively, p = .0047). Average allowed cost for the combined inpatient and 30-day post-discharge period was lower for laparoscopic vs open colectomy cases ($36,395 and $44,226, respectively, p < .001).

CONCLUSIONS

The cost of laparoscopic colectomy was found to be statistically significantly less than that of open colectomy in patients undergoing elective surgery for colon cancer.

Outcomes of laparoscopic surgery in pathologic T4 colon cancers compared to those of open surgery

INTRODUCTION

Despite the oncologic safety of laparoscopic surgery in colon cancer management, laparoscopy is not regarded as a standard treatment for T4 colon cancer. The aim of this study was to investigate the short-term and long-term oncologic outcomes of laparoscopic surgery in patients with locally advanced colon cancer.

MATERIAL AND METHOD

From March 2003 to June 2013, a total of 109 consecutive patients with proven pathologic T4 colon cancer were enrolled. These patients were divided into the laparoscopy group (LG, n = 52) and the open group (OG, n = 57). Perioperative and long-term oncologic outcomes were compared between the two groups.

RESULTS

In the LG, open conversion occurred in four patients (7.6%). Combined resection was less commonly performed in the LG (13.5%) than in the OG (36.8%, P = 0.005). Operation time was similar between the two groups. In the LG, blood loss (129 mL vs. 437 mL, P < 0.001) and overall complication rate (13.5 vs. 36.8%, P = 0.005) were lower and length of hospital stay was shorter (median 7 vs. 17 days, P < 0.001) than in the OG. The 5-year overall survival rate was 60.7% for the LG and 61.9% for the OG (P = 0.817). Local recurrence-free survival did not differ between the groups (88.9% in LG vs. 88.1% in OG, P = 0.725).

CONCLUSION

Considering the benefits of early recovery and similar oncologic outcomes, laparoscopic surgery in T4 colon cancer could be a viable option in selected patients.

Predicting opportunities to increase utilization of laparoscopy for colon cancer

BACKGROUND

Despite proven safety and efficacy, rates of minimally invasive approaches for colon cancer remain low in the USA. Given the known benefits, investigating the root causes of underutilization and methods to increase laparoscopy is warranted. Our goal was to develop a predictive model of factors impacting use of laparoscopic surgery for colon cancer.

METHODS

The Premier Hospital Database was reviewed for elective colorectal resections for colon cancer (2009-2014). Patients were identified by ICD-9-CM diagnosis code and then stratified into open or laparoscopic approaches by ICD-9-CM procedure codes. An adjusted multivariate logistic regression model identified variables predictive of use of laparoscopy for colon cancer.

RESULTS

A total of 24,245 patients were included-12,523 (52 %) laparoscopic and 11,722 (48 %) open. General surgeons performed the majority of all procedures (77.99 % open, 71.60 % laparoscopic). Overall use of laparoscopy increased from 48.94 to 52.03 % over the study period (p < 0.0001). Patients with private insurance were more likely to have laparoscopy compared with Medicare patients (adjusted odds ratio (OR) 1.089, 95 % CI [1.004, 1.181], p = 0.0388). Higher volume of surgeons (OR 3.518, 95 % CI [2.796, 4.428], p < 0.0001) and larger hospitals by bed size were more likely to approach colon cancer laparoscopically. Colorectal surgeons were 32 % more likely to approach a case laparoscopically than general surgeons (OR 1.315, 95 % CI [1.222, 1.415], p < 0.0001). Teaching hospitals, hospitals in the Midwest, and hospitals with less than 500 beds were less likely to use laparoscopy.

CONCLUSIONS

There are patient, provider, and hospital characteristics that can be identified preoperatively to predict who will undergo surgery for colon cancer using laparoscopy. However, additional patients may be eligible for laparoscopy based on patient-level characteristics. These results have implications for regionalization and increasing teaching of MIS. Recognizing and addressing these variables with training and recruiting could increase use of minimally invasive approaches, with the associated clinical and financial benefits.

Time to Initiation of Adjuvant Chemotherapy in Colon Cancer: Comparison of Open, Laparoscopic, and Robotic Surgery

BACKGROUND

The time to initiation of adjuvant chemotherapy (TIC) can be used as a recovery parameter after surgery. The effect of laparoscopic or robotic surgery on TIC has not been thoroughly studied. This study aimed to compare the impact of open, laparoscopic, and robot-assisted surgery on TIC after colon cancer surgery.

MATERIALS AND METHODS

Patients who underwent curative resection for stage II or III colon cancer between January 2007 and June 2013 and who received adjuvant chemotherapy from surgeons capable of performing open, laparoscopic, and robotic surgeries were included in this study. Patient demographics, clinicopathologic variables, and TIC were compared among the three groups. Univariate and multivariate analyses were performed to identify factors affecting TIC.

RESULTS

Of the 252 patients, 40, 161, and 51 patients underwent open, laparoscopic, and robotic colectomy, respectively. The postoperative complication rate was lower in the laparoscopic and robotic groups compared to the open group (P = .002). The length of hospital stay was shorter in the laparoscopic group compared with the open and robotic groups (P < .001). Multivariate analysis revealed that the operation method was the only factor affecting TIC, with laparoscopic and robotic surgery being favorable (regression coefficient -5.1, 95% confidence interval -7.6 to -2.6; P < .001). However, there was no difference in TIC between the laparoscopic and robotic group.

CONCLUSIONS

Laparoscopic and robotic surgeries were associated with shorter TIC. This study demonstrates another benefit of minimally invasive surgery with regard to early initiation of adjuvant chemotherapy.

Factors Predicting Difficulty of Laparoscopic Low Anterior Resection for Rectal Cancer with Total Mesorectal Excision and Double Stapling Technique

BACKGROUND

Laparoscopic sphincter-preserving low anterior resection for rectal cancer is a surgery demanding great skill. Immense efforts have been devoted to identifying factors that can predict operative difficulty, but the results are inconsistent.

OBJECTIVE

Our study was conducted to screen patients' factors to build models for predicting the operative difficulty using well controlled data.

METHOD

We retrospectively reviewed records of 199 consecutive patients who had rectal cancers 5-8 cm from the anal verge. All underwent laparoscopic sphincter-preserving low anterior resections with total mesorectal excision (TME) and double stapling technique (DST). Data of 155 patients from one surgeon were utilized to build models to predict standardized endpoints (operative time, blood loss) and postoperative morbidity. Data of 44 patients from other surgeons were used to test the predictability of the built models.

RESULTS

Our results showed prior abdominal surgery, preoperative chemoradiotherapy, tumor distance to anal verge, interspinous distance, and BMI were predictors for the standardized operative times. Gender and tumor maximum diameter were related to the standardized blood loss. Temporary diversion and tumor diameter were predictors for postoperative morbidity. The model constructed for the operative time demonstrated excellent predictability for patients from different surgeons.

CONCLUSIONS

With a well-controlled patient population, we have built a predictable model to estimate operative difficulty. The standardized operative time will make it possible to significantly increase sample size and build more reliable models to predict operative difficulty for clinical use.

Timing of adjuvant chemotherapy and its relation to survival among patients with stage III colon cancer

BACKGROUND

Currently available data suggest that delaying the start of adjuvant chemotherapy in colon cancer patients has a detrimental effect on survival. We analysed which factors impact on the timing of adjuvant chemotherapy and evaluated the influence on overall survival (OS).

PATIENTS AND METHODS

Stage III colon cancer patients who underwent resection and received adjuvant chemotherapy between 2008 and 2013 were selected from the Netherlands Cancer Registry. Timing of adjuvant chemotherapy was subdivided into: ⩽ 4, 5-6, 7-8, 9-10, 11-12 and 13-16 weeks post-surgery. Multivariable regressions were performed to assess the influence of several factors on the probability of starting treatment within 8 weeks post-surgery and to evaluate the association of timing of adjuvant chemotherapy with 5-year OS.

RESULTS

6620 patients received adjuvant chemotherapy, 14% commenced after 8 weeks. Factors associated with starting treatment after 8 weeks were older age (Odds ratio (OR) 65-74 versus < 65 years 1.3 (95% confidence interval (CI): 1.14-1.58); OR ⩾ 75 versus < 65 years 1.6 (1.25-1.94)), emergency resection (OR 1.8 (1.41-2.32)), anastomotic leakage (OR 8.1 (6.14-10.62)), referral to another hospital for adjuvant chemotherapy (OR 1.9 (1.36-2.57)) and prolonged postoperative hospital admission (OR 4.7 (3.30-6.68)). Starting 5-8 weeks post-surgery showed no decrease in OS compared to initiation within 4 weeks (Hazard ratio (HR) 5-6 weeks 0.9 (0.79-1.11); HR 7-8 weeks 1.1 (0.91-1.30)). However, commencing beyond 8 weeks was associated with decreased OS compared to initiation within 8 weeks (HR 9-10 weeks 1.4 (1.21-1.68); HR 11-12 weeks 1.3 (1.06-1.59); HR 13-16 weeks 1.7 (1.23-2.23)).

CONCLUSION

Our data support initiating adjuvant chemotherapy in stage III colon cancer patients within 8 weeks post-surgery.

Significant reduction in the incidence of small bowel obstruction and ventral hernia after laparoscopic compared to open segmental colorectal resection

PURPOSE

The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection.

METHODS

A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling.

RESULTS

Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49% were males. Colorectal carcinoma (45%) and diverticulitis (18%) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5%, compared to 5.7, 8.7, and 10.8% in the laparoscopic cohort (p < 0.001). Similarly, small bowel obstruction was higher in the open compared to the laparoscopic group (open 10.4, 15.0, and 18.3% vs. laparoscopic 2.7, 4.4, and 5.5%, p < 0.001). Patients undergoing laparoscopic colorectal resection were less likely to develop ventral hernia [adjusted hazard ratio (AHR) 0.64 (95% CI 0.52, 0.80); p < 0.0001] and small bowel obstruction [AHR 0.41 (95% CI 0.31, 0.54); p < 0.0001].

CONCLUSIONS

The incidence of incisional ventral hernia and small bowel obstruction is significantly reduced in patients who undergo laparoscopic compared to open colorectal resection.