Evidence based medicine and surgical approaches for colon cancer: Evidences, benefits and limitations of the laparoscopic vs open resection

Efficacy and safety of reduced-port laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic radical resection has become the most important treatment for resectable colorectal cancer (CRC). However, there is still a lack of researches on the efficacy and safety of reduced-port laparoscopic surgery (RPLS) versus conventional laparoscopic surgery (CLS) in the treatment of CRC.

PATIENTS AND METHODS

From January 2019 to July 2022, 698 patients with CRC received surgical treatment in the Sixth Affiliated Hospital of Sun Yat-sen University were enrolled in this retrospective cohort study. Patients were divided into RPLS group (n = 220) and CLS group (n = 478) according to their surgical procedures. Propensity score matching (PSM) was used to adjust the differences in baseline characteristics. The incidence of perioperative outcomes and survival rates related results were analyzed after PSM.

RESULTS

Four hundred twenty-two patients were equally divided into RPLS group (n = 211) and CLS group (n = 211) after PSM. There were no statistically significant differences in overall survival (OS) and progression-free survival (PFS) between the two groups (P value was 0.773 and 0.579 respectively). The perioperative outcomes of patients between the two groups were comparable, except that patients in the RPLS group had a shorter postoperative hospital stay (P value < 0.001).

CONCLUSION

For patients with CRC, both RPLS and CLS might be acceptable surgical options. No significant differences in perioperative outcomes, PFS rates and OS rates were observed between the two groups. For certain cases, RPLS was superior to CLS in terms of postoperative recovery.

The use of mixed reality in the preoperative planning of colorectal surgery: Preliminary experience with a narrative review

New advanced technologies have recently been developed and preliminarily applied to surgery, including virtual reality (VR), augmented reality (AR) and mixed reality (MR). We retrospectively review all colorectal cases in which we used holographic 3D reconstruction from February 2020 to December 2022. This innovative approach was used to identify vascular anomalies, pinpoint tumor locations, evaluate infiltration into neighboring organs and devise surgical plans for both training and educating trainee assistants. We have also provided a state-of-the-art analysis, briefly highlighting what has been stated by the scientific literature to date. VR facilitates training and anatomical assessments, while AR enhances training and laparoscopic performance evaluations. MR, powered by HoloLens, enriches anatomic recognition, navigation, and visualization. Successful implementation was observed in 10 colorectal cancer cases, showcasing the effectiveness of MR in improving preoperative planning and its intraoperative application. This technology holds significant promise for advancing colorectal surgery by elevating safety and reliability standards.

Immune microenvironment and lymph node yield in colorectal cancer

BACKGROUND

Lymph node (LN) harvesting is associated with outcomes in colonic cancer. We sought to interrogate whether a distinctive immune milieu of the primary tumour is associated with LN yield.

METHODS

A total of 926 treatment-naive patients with colorectal adenocarcinoma with more than 12 LNs (LN-high) were compared with patients with 12 or fewer LNs (LN-low). We performed immunohistochemistry and quantification on tissue microarrays for HLA class I/II proteins, beta-2-microglobulin (B2MG), CD8, CD163, LAG3, PD-L1, FoxP3, and BRAF V600E.

RESULTS

The LN-high group was comprised of younger patients, longer resections, larger tumours, right-sided location, and tumours with deficient mismatch repair (dMMR). The tumour microenvironment showed higher CD8+ cells infiltration and B2MG expression on tumour cells in the LN-high group compared to the LN-low group. The estimated mean disease-specific survival was higher in the LN-high group than LN-low group. On multivariate analysis for prognosis, LN yield, CD8+ cells, extramural venous invasion, perineural invasion, and AJCC stage were independent prognostic factors.

CONCLUSION

Our findings corroborate that higher LN yield is associated with a survival benefit. LN yield is associated with an immune high microenvironment, suggesting that tumour immune milieu influences the LN yield.

A standardized stepwise approach to minimally invasive ileocolic anastomosis: Tips and tricks for laparoscopic and robotic surgery

AIM

Intracorporeal anastomosis has been associated with earlier recovery of postoperative bowel function, shorter length of stay and lower surgical site infection rates. The aim of this work is to describe a step-by-step standardized technique for intracorporeal ileocolic and ileosigmoid anastomosis suitable for laparoscopic and robotic colectomy.

METHOD

Each step of the technique is illustrated using a composite collection of three operative patient videos. Two procedures were performed robotically and one was laparoscopic. Tips are provided to construct a two-layer anastomosis (both posteriorly and anteriorly). The procedures are presented in stepwise fashion, discussing the advantages and feasibility of the technique.

RESULTS

The standardized technique described herein was used in three patients for this report, of whom two underwent right colectomy and one subtotal colectomy for cancer. The median operating time was 255 (206-333) min. There were no intraoperative complications. No major postoperative complications or 30-day readmissions occurred. The median length of stay was 4 (3-5) days.

CONCLUSION

The described technique of a two-layer anastomosis can be used with any available minimally invasive approach. It is safe and feasible. Using a standardized approach, the technique can be easily taught and mastered, optimizing operating times and reducing adverse events.

Laparoscopic synchronous resection of rectal cancer and liver metastases: A case report and review of the literature

Introduction and importance

During the past decade, there are several studies which showed the advantages of the laparoscopic approach for treating colorectal cancer (CRC) or colorectal cancer liver metastasis (CRCLM). However, in contrast, there are only a few reports of combined one stage synchronous laparoscopic colorectal and liver metastasis resection, cold one stage minimally invasive approach (MIA).

Case presentation

Our patient was 51 years old woman.

Rectal adenocarcinoma was verified three centimeters from the anal verge. Magnetic resonance imaging (MRI) with rectal protocol modification indicated T1N0MO stage. We decided to do transanal local excision and achieved R0 resection. Half a year after the operation on the control MRI, lymphadenopathy was found along the rectum and possible recurrence of cancer. Also on the MRI was shown solitary, 4.7 × 2.7 × 3.8 cm big metastasis in the IVa/VIII segment of the liver. The patient was shown on a multidisciplinary team and it was decided to do laparoscopic synchronous resection of rectum and liver metastases.

Clinical discussion

During the last decades many articles with different strategies for treating CRC and liver metastasis were published. Some of them prefered two-stage surgical treatment, like liver first approach which allows initial control of liver metastases, and delivery of preoperative radiotherapy for rectal cancer without the fear that liver metastases will meanwhile progress beyond the possibility of cure. Alternatively, the colon first approach is where the adjuvant chemotherapy is combined with the resection of the primary colorectal tumour with liver resection being undertaken (if at all) as a subsequent operation. By developing surgery, anaesthesia and critical care, the one stage approach for patients with CRC and liver metastasis started to be a reasonable option.

Conclusion

Totally laparoscopic synchronous resection of the colorectal cancer and synchronous colorectal liver metastasis is technically feasible and safe in the hands of the experienced abdominal surgeon. This type of approach offers all the benefits of the laparoscopic minimally invasiveness associated with good oncological outcomes, and it is indicated in well-selected patients. However, the real scientific answer to this question can be given just with randomised control trial which will be a real challenge for endoscopic surgeons in the future.

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Colorectal cancer is the third most common cancer in the world.

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TLSR of the colorectal cancer and SCRLM is technically feasible and safe in the hands of the experienced abdominal surgeon

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This type of approach offers all the benefits of the laparoscopic minimally invasiveness associated with good outcomes

Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites

BACKGROUND

Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors.

OBJECTIVE

The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use.

DESIGN

This was a population-based retrospective analysis from April 2008 to March 2015.

SETTINGS

All Canadian provinces (excluding Quebec) were included.

PATIENTS

The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer.

MAIN OUTCOME MEASURES

The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center.

RESULTS

A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001).

LIMITATIONS

Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias.

CONCLUSIONS

Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595.

VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES

ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

Prognostic Discrimination of Alternative Lymph Node Classification Systems for Patients with Radically Resected Non-Metastatic Colorectal Cancer: A Cohort Study from a Single Tertiary Referral Center

BACKGROUND

Lymph node ratio (LNR) and the Log odds of positive lymph nodes (LODDS) have been proposed as a new prognostic indicator in surgical oncology. Various studies have shown a superior discriminating power of LODDS over LNR and lymph node category (N) in diverse cancer entities, when examined as a continuous variable. However, for each of the classification systems various cut-off values have been defined, with the question of the most appropriate for patients with CRC still remaining open. The present study aimed to compare the predictive impact of different lymph node classification systems and to define the best cut-off values regarding accurate evaluation of overall survival in patients with resectable, non-metastatic colorectal cancer (CRC).

METHODS

CRC patients who underwent surgical resection from 1996 to 2018 were extracted from our medical data base. Cox proportional hazards regression models and C-statistics were performed to assess the discriminative power of 25 LNR and 26 LODDS classifications. Regression models were adjusted for age, sex, extent of the tumor, differentiation, tumor size and localization.

RESULTS

Our study group consisted of 654 consecutive patients with non-metastatic CRC. C-statistic revealed 2 LNR and 5 LODDS classifications that demonstrated superior prognostic performance in patients with UICC III CRC, compared to the N category. No clear advantage of one classification over another could be demonstrated in any other patient subgroup.

CONCLUSIONS

Distinct LNR and LODDS classifications demonstrate a prognostic superiority over the N category only in patients with Stage III radically resected CRC.

Anatomical framework for pre-operative planning of laparoscopic left-sided colorectal surgery: Potential relevance of the distance between the inferior mesenteric artery and inferior mesenteric vein

BACKGROUND

The medial-to-lateral approach is favored by most colorectal surgeons for laparoscopic retroperitoneal dissection and mobilisation of the left colon. The peritoneal access window, i.e. the distance between the inferior mesenteric vein (IMV) and inferior mesenteric artery (IMA) must be large enough to perform the procedure safely and successfully. However, studies investigating the IMA-IMV distance and factors affecting this variable, are scarce. Therefore, we examined the IMA-IMV and D3-IMA distances to determine an anatomical framework on planning and adapting surgical therapy.

BASIC PROCEDURES

The IMA-IMV and D3-IMA distances were retrospectively measured in 230 patients (127 Male/103 Female, Median Age=54.5) who had undergone pre-operative CT-scanning before laparoscopic left-sided colorectal surgery. Two observers rated the images and interrater reliability was calculated. Subgroup, simple and multiple linear regression analyses were performed in order to detect potential interaction between morphometric variables and IMA-IMV distance.

MAIN FINDINGS

We demonstrated a significant correlation between the inferior margin of the duodenum and the origin of IMA. Determination of the IMA-IMV distance was simple and reproducible. Approximately 45% of patients undergoing laparoscopic colorectal procedures had a narrow distance (≤50mm). There was a sexual dimorphism in IMA-IMV distance, being consistently large in males. There were no other pre-operative factors which predicted whether the peritoneal dissection window for a medial-to-lateral approach was sufficient.

CONCLUSIONS

Our results provide new data for a better understanding of metric variations in abdominal vascular structures and complement previous observations. In view of our results, we recommend pre-operative measurement of the IMA-IMV before colorectal surgery where the medial-to-lateral approach is planned. Given that a narrow distance may predict a difficult dissection, this factor should be taken into account to determine the optimal surgical approach in each patient.

Minimally invasive surgery for T4 colon cancer is associated with better outcomes compared to open surgery in the National Cancer Database

Minimally invasive surgery (MIS) is favored for T1-T3 colon cancer resection due to improved short and long-term outcomes. Recommendations regarding T4 cancers remain controversial due to a paucity of clinical trials or large datasets assessing outcomes. We aim to compare outcomes for pT4 colon cancer patients treated with MIS or open surgery (OS) in the National Cancer Database (NCDB). We analyzed adults having MIS or OS for stage II or III pT4 colon cancers between 2010 and 2014 using propensity-score matching, Cox and logistic regression modeling. Of 21 998 T4 patients, 7532 (34.2%) underwent MIS, 14 466 (65.8%) OS and 22.3% were MIS converted to OS. After propensity score matching, 5624 patients in each cohort were included. MIS was associated with improved postoperative mortality (3.4 vs. 7.2%, p > .001), surgical margins, optimal lymph node harvest, adjuvant chemotherapy use and 5-year survival (46% vs. 41%, P < .001). MIS was associated with improved short and long term outcomes for T4 colon cancers compared to OS on multivariate analysis. Based on these findings, well selected pT4 colon cancers can be considered appropriate for MIS however, prospective clinical trials are needed to better define the role of MIS in T4b colon cancer.

Clinical efficacy and quality of life after transrectal natural orifice specimen extraction for the treatment of middle and upper rectal cancer

Background

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) avoids extra abdominal extraction incision during colorectal surgery. Some surgeons realized the benefits of NOSE on clinical efficacy. We compared the clinical efficacy of laparoscopic NOSE, laparoscopic non-NOSE and open surgery (OS) for short-term recovery and quality of life (QoL).

Methods

A single randomized controlled trial of NOSE for middle and upper rectal cancer between April 2014 and February 2018. Preoperative and postoperative clinical variables were analyzed and compared between the groups. Preoperative and 6 months postoperative QoL was assessed with the SF-36 QoL questionnaire.

Results

A total of 378 patients were enrolled, 334 patients randomly divided into NOSE group (n=104), non-NOSE group (n=119), OS group (n=111). The NOSE group was superior to the other two groups on the QoL after surgery. The NOSE group had the lowest postoperative VAS score between three groups. The postoperative time for bowel function recovery and the length of hospital stay was statistically significantly different among the three groups, with the NOSE group having the shortest time. The incidence of postoperative complications was lower in the NOSE group (12/104, 11.5%) than in the non-NOSE group (20/119, 16.8%), the difference was statistically significant. The Kaplan-Meier (K-M) survival curve showed no statistically significant difference in the disease-free survival (DFS) rate between the three groups.

Conclusions

Comparing NOSE to non-NOSE and OS, the NOSE had significantly better functional recovery and better QoL. The NOSE group had a significant lower surgical complication rate than the non-NOSE group.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis

BACKGROUND

Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis.

RESULTS

Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03).

CONCLUSION

These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Complex abdominal wall hernias as a barrier to quality of life in cancer survivors

Background

Many cancer survivors live with postoperative complex abdominal wall hernias (CAWHs). However, the impact of CAWHs on their quality of life is unknown, and few descriptions of patient experiences exist. We performed a qualitative study to explore cancer survivors’ experience with CAWHs before and after repair.

Methods

Patients waiting to undergo CAWH repair or who had completed the surgery in the previous 18 months were identified from a single surgeon’s practice in CAWH at a tertiary care centre. Clinical and demographic data were extracted from the electronic patient record. An in-depth semistructured interview guide was developed by experts in CAWH and qualitative methodology. Interviews were conducted in March 2013. We used comparative analysis techniques and coding strategies to identify themes.

Results

Ten preoperative and 12 postoperative participants were interviewed. The average age of the participants was 64 years in both groups, with an even sex distribution. The most frequently diagnosed cancer in both groups was colorectal cancer. Participants’ views were organized into 5 themes: 1) unable to return to normal life, 2) sense of abandonment, 3) experiencing fear and distress, 4) preoperative: desperate for help and 5) postoperative: “getting my life back.”

Conclusion

Our findings show the all-encompassing impact of a CAWH on the life of cancer survivors. They strongly suggest that hernia management should be viewed as an integral part in the continuum of cancer treatment to improve the quality of life of cancer survivors with hernias.

[Short- and long-term outcomes of laparoscopic interventions in patients with colon cancer: single-centre experience]

OBJECTIVE

To compare short- and long-term outcomes of treatment in patients with colon cancer undergoing laparoscopic and open surgery.

MATERIAL AND METHODS

There were 281 patients with colon cancer. All patients underwent open (n=144, 51.2%) or laparoscopic (n=137, 48.8%) procedures. Short- and long-term outcomes of treatment were compared in both groups.

RESULTS

There were no significant differences in sex, age, body mass index, location of tumors and tumor differentiation grade in both groups. Conversion was required in 10 (7.2%) cases. The median of duration of surgery was greater for laparoscopic procedures (150 min vs. 130 min; p<0.001). Intraoperative blood loss was significantly less in laparoscopic surgery (100 ml vs. 300 ml; p=0.001). Postoperative mortality was similar (3.5% vs. 2.5%; p=0.5) while incidence of postoperative complications was significantly lower after laparoscopic interventions (13.1% vs. 22.2%; p=0.04). There was earlier recovery of the gastrointestinal tract after laparoscopic procedures (2.1±0.9 days vs. 3.6±1.5 days, respectively; p<0.001). The postoperative hospital-stay was significantly less in the 2^nd group (p<0.001). Two-year disease -free and overall survival was similar in both groups.

CONCLUSION

Laparoscopic interventions for colon cancer are followed by similar overall and disease-free 2-year survival and better early outcomes.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

Outcomes of open versus laparoscopic surgery in patients with colon cancer

OBJECTIVE

There is limited information on health service use or patient-reported outcomes when comparing the effectiveness of laparoscopic with that of open surgery. The aim was to compare the effectiveness of laparoscopic with that of open surgery up to 2 years after intervention in patients with colon cancer.

METHODS

Prospective cohort study of patients with colon cancer who underwent surgery (laparoscopic or open surgery) between June 2010 and December 2012, at 22 hospitals. Main outcomes of the study were mortality, complications, reoperation, readmission, and patient-reported outcome measures (PROMs), as measured using the Hospital Anxiety and Depression Scale, Duke-UNC, EuroQol-5D, and European Organisation for Research and Treatment of Cancer-Q30 and Q29 at baseline, and 30 days and 1 and 2 years after surgery. Multivariable multilevel logistic regression and generalized linear models were used in analyses after adjusting for specific propensity scores developed for each outcome and time point.

RESULTS

In the multivariable analysis, the complication rates up to 30 days (infectious, surgical, and medical) and 1 year (surgical), and readmission rate at 30 days and at 2 years were higher among patients who underwent open surgery than among those who underwent laparoscopic surgery. There were no differences between the two surgical approaches in all other parameters assessed and in changes of all PROMs.

CONCLUSIONS

Though in most outcomes both surgical approaches provide similar results up to 2 years after intervention, still the rates of some complications and readmission, mainly up to 30 days, are higher in open surgery. CLINICALTRIALS.

GOV IDENTIFIER

NCT02488161.

Predictors of adequate lymph node harvest during colectomy for colon cancer

BACKGROUND

Consensus guidelines recommend a yield of 12 lymph nodes in resections for colon cancer. Factors affecting this yield are not well defined.

METHODS

Retrospective study using the colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program for years 2014-2016. Primary outcome was resection of at least 12 nodes. Univariate and multivariate analyses determined factors associated with ≥12 LN yield.

RESULTS

17,612 colectomies for colon cancer were extracted from the NSQIP database. 7.26% of cases did not reach a 12 LN harvest. Harvesting ≥12 LN was 74% more likely (p = 0.001) if the resection was laparoscopic and 72% more likely (p < 0.0001) if hand-assisted. Advanced T and N stage had a higher likelihood of reaching 12 LN harvest. Older age, female gender and smoking history decreased the likelihood of ≥12 LN harvest.

CONCLUSIONS

Laparoscopic and robotic colectomies were 1.5-2.5 times more likely to achieve adequate LN harvest compared to open surgery. Several non-modifiable patient and disease related factors may render adequate LN yield challenging.

Improved perioperative care is associated with improved long-term survival in colorectal cancer

PURPOSE

To compare perioperative colorectal cancer care and survival in patient cohorts operated in 2005 and in 2010 in Lithuania.

METHODS

Comparative observational cohort study was performed. The study was conducted in the three Lithuanian cancer hospitals. Patients, who underwent curative surgery for colorectal cancer in 2005 and 2010, were included. Demographic characteristics, distribution of the tumors, preoperative diagnostics and staging, surgical treatment, the quality of pathological examination, morbidity, and mortality were analyzed. One- and 5-year overall survival data were compared between the groups.

RESULTS

Colorectal cancer diagnostics and treatment improved from 2005 to 2010 significantly. The disease was identified as stage III-IV for 45 vs. 48% of the patients; however, computed tomography staging scan was performed only for 5.9 vs. 17.8% in 2005 and 2010, respectively. Laparoscopic operations were performed 1.5 vs. 10.5% and abdominoperineal resections-42.7 vs. 31.7% in 2005 and 2010, respectively. The number of harvested lymph nodes was mentioned in 55.8 vs. 97.7% of the cases, whereas more than 12 lymph nodes were examined in 18 vs. 66.6% of cases after histological examination. The overall 5-year survival was 52.1 vs. 63.1% (p < 0.0001), while the 5-year survival of the patients with stage IV of disease was 4.2 vs. 17.8% in 2005 and 2010, respectively.

CONCLUSION

Preoperative investigation, surgical treatment, pathological examination, and postoperative course are associated with improved overall survival in colorectal cancer patients, undergoing curative surgery in the resource-limited settings.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Comparison of the short-term outcomes of reduced-port laparoscopic surgery and conventional multiport surgery in colon cancer: a propensity score matching analysis

Purpose

The feasibility of reduced-port laparoscopic surgery (RPS) in colon cancer remains uncertain. This study aimed to compare the short-term outcomes of RPS and multiport surgery (MPS) in colon cancer using propensity score matching analysis.

Methods

A total of 302 patients with colon cancer who underwent laparoscopic anterior resection (AR) (n = 184) or right hemicolectomy (RHC) (n = 118) by a single surgeon between January 2011 and January 2017 were included. Short-term outcomes were compared between RPS and MPS.

Results

Seventy-three patients in the AR group and 23 in the RHC group underwent RPS. After propensity score matching, the RPS and MPS groups showed similar baseline characteristics. In the AR group, patients who underwent RPS (n = 72) showed a shorter operation time (114.4 ± 28.7 minutes vs. 126.7 ± 34.5 minutes, P = 0.021) and a longer time to gas passage (3.6 ± 1.7 days vs. 2.6 ± 1.5 days, P = 0.005) than MPS (n = 72). Similarly, in the RHC group, the operation time was shorter (112.6 ± 26.0 minutes vs. 146.5 ± 31.2 minutes, P = 0.005), and the time to first flatus was longer (2.7 ±1.1 days vs. 3.8 ± 1.3 days, P = 0.004) in the RPS group (n = 23) than in the MPS group (n = 23). Other short-term outcomes were similar for RPS and MPS in both the AR and RHC groups.

Conclusion

The short-term outcomes of RPS were found to be acceptable compared to those of MPS in colon cancer surgery.

Down-regulated miRs specifically correlate with non-cardial gastric cancers and Lauren's classification system

BACKGROUND AND OBJECTIVES

Gastric cancers are usually characterized using Lauren's classification into intestinal and diffuse types. We previously documented the down-modulation of miR31, miR148a, miR204, and miR375 in gastric cancers. We aimed this manuscript to investigate these miRs with the end-points of diagnosis, Lauren's classification and prognosis.

METHODS

A total of 117 resected non-cardial adenocarcinomas were evaluated for miRs' expressions. The performance of miRs' expressions for cancer diagnosis was tested using ROC curves. Logistic regression was conducted with the end-point of Lauren's classification. Kaplan-Meier and Cox analyses were performed for OS, DFS, and DSS. miRs' targets were reviewed using PRISMA method and BCL-2 was further investigated in cell lines.

RESULTS

ROC curves documented that miRs' down-modulation was significant in differentiating cancer versus normal tissues. Diffuse type cancers were associated with female sex, young age, and miR375 higher expression. We confirmed BCL-2 as a miR204 target. However, survival analyses confirmed the pathologic criteria (advanced stages, LNR, and low LNH) as the significant variables correlated to worse prognosis.

CONCLUSIONS

The down-modulation of miR31, miR148a, miR204, and miR375 is significantly associated with non-cardial gastric cancers and miR375 is specifically linked to Lauren's classification. Nevertheless, standard pathological features display as the independent variables associated with worse prognosis.

Oncologic Outcomes Following Laparoscopic versus Open Resection of pT4 Colon Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Locally advanced colon cancer is considered a relative contraindication for laparoscopic resection, and clinical trials addressing the oncologic safety are lacking.

OBJECTIVE

The aim of this study was to synthesize the oncologic outcomes associated with laparoscopic versus conventional open surgery for locally advanced colon cancers.

DATA SOURCES

We systematically searched Medline, Embase, Central, and ClinicalTrials.gov.

STUDY SELECTION

Two reviewers independently screened the literature for controlled trials or observational studies comparing curative-intent laparoscopic and open surgery for colon cancer. Studies were included if it was possible to determine outcomes for the T4 colon cancers separately, either reported in the article or calculated with individual patient data.

INTERVENTIONS

Included studies were systematically reviewed and assessed for risk of bias. Meta-analyses were done by using random-effects models.

MAIN OUTCOME MEASURES

Outcomes of interest were disease-free survival, overall survival, resection margins, and lymph node harvest.

RESULTS

Of 2878 identified studies, 5 observational studies met eligibility criteria with a total of 1268 patients (675 laparoscopic, 593 open). There was no significant difference in overall survival (HR, 1.28; 95% CI, 0.94-1.72), disease-free survival (HR, 1.20; 95% CI, 0.90-1.61), or positive surgical margins (OR, 1.16; 95% CI, 0.58-2.32) between the groups. The open group had a larger lymph node retrieval (pooled mean difference, 2.26 nodes; 95% CI, 0.58-3.93). The pooled rate of conversion from laparoscopy to an open procedure was 18.6% (95% CI, 9.3%-27.9%).

LIMITATIONS

These results are limited by the inherent selection bias in the included nonrandomized studies.

CONCLUSIONS

Based on the available literature, minimally invasive resection of selected locally advanced colon cancer is oncologically safe. There is a small increase in lymph node harvest with open resections, but it is unclear whether this is clinically significant. Surgeons should be prepared for a significant rate of conversion to laparotomy as required to perform en bloc resection.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PURPOSE

Surgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases.

METHODS

Data on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases.

RESULTS

Based on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st-44th case); phase 2, the consolidation period (45th-90th case); and phase 3, the mastery period (91th-108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases.

CONCLUSIONS

The learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery

Purpose

Laparoscopic surgery was previously accepted as an alternative surgical option in treatment for colorectal cancer. Nowadays, single-port laparoscopic surgery (SPLS) is introduced as a method to maximize advantages of minimally invasive surgery. However, SPLS has several limitations compared to conventional multiport laparoscopic surgery (CMLS). To overcome those limitations of SPLS, reduced port laparoscopic surgery (RPLS) was introduced. This study aimed at evaluating the short-term outcomes of RPLS.

Methods

Patients who underwent CMLS and RPLS of colon cancer between August 2011 and December 2013 were included in this study. Short-term clinical and pathological outcome were compared between the 2 groups.

Results

Thirty-two patients underwent RPLS and 217 patients underwent CMLS. Shorter operation time, less blood loss, and faster bowel movement were shown in RPLS group in this study. In terms of postoperative pain, numeric rating scale (NRS) of RPLS was lower than that of CMLS. Significant differences were shown in terms of tumor size, harvested lymph node, perineural invasion, and pathological stage. No significant differences were confirmed in terms of other surgical outcomes.

Conclusion

In this study, RPLS was technically feasible and safe. Especially in terms of postoperative pain, RPLS was comparable to CMLS. RPLS may be a feasible alternative option in selected patients with colon cancer.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample

Background

The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.

Methods

We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.

Results

A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.

Conclusion

Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Real-world cost-effectiveness of laparoscopy versus open colectomy for colon cancer: a nationwide population-based study

BACKGROUND

Laparoscopic colectomy is increasingly being adopted for the treatment of colon cancer; however, the long-term effectiveness of this approach in a real-world clinical setting has yet to be verified. This study aims to compare the effectiveness and costs associated with laparoscopic and open colectomy from the perspective of the National Health Insurance (NHI) system in Taiwan.

METHODS

A nationwide population-based colon cancer cohort was observed by linking the Taiwan Cancer Registry, claims data from NHI system, and the National Death Registry. Adult patients with Stage I to Stage III colon cancer who underwent primary cancer resection using either laparoscopy or open colectomy between 2009 and 2011 were included. A propensity score-matched cohort (1745 pairs) was applied to examine three clinical endpoints: overall survival, recurrence-free survival, and disease-free survival within 2 years after the operation. To comply with the perspective as well as the analytic horizon of the study, we limited the research to NHI claims from the study population for the corresponding time period. The health outcomes and net monetary benefits were verified by multivariate mixed-effect models.

RESULTS

This analysis revealed that laparoscopy resulted in longer overall survival (adjusted difference 16.8 days, 95 % CI 7.3-26.2), recurrence-free survival (16.8 days, 5.0-28.6) and disease-free survival (26.4 days, 7.4-45.4), compared to open colectomy at 2 years post-op. Laparoscopy also led to a significantly shorter length of stay (3.2 days, 2.4-3.9) and lower index hospitalization costs (US$ 455, 181-729) than open colectomy; however, no differences in costs were observed over the long term. Overall, laparoscopy was more cost-effective than open colectomy under various willingness-to-pay thresholds in the setting of the Taiwan NHI.

CONCLUSIONS

The continued adoption of laparoscopy in primary curable colon cancer resection is expected to reduce health care costs over the short term while providing considerable health benefits over the long term.

Laparoscopic versus robotic-assisted colectomy and rectal resection: a systematic review and meta-analysis

PURPOSE

Lately, the main technical innovations in the field of colorectal surgery have been the introduction of laparoscopic and robotic techniques; the aim of this study is to investigate the results and the advantages of these two surgical approaches.

METHODS

Twenty-two studies including 1652 laparoscopic and 1120 robotic-assisted resections were analyzed and categorized into right, left, and pelvic resections of the middle/low rectum, aiming to the following outcomes: operating time, blood loss, bowel function recovery, return to oral intake, morbidity, hospital stay, and costs.

RESULTS

The vast majority of the studies were non-randomized investigations (19/22 studies) enrolling small cohorts of patients (median 55.0 laparoscopic and 34.5 robotic-assisted group) with a mean age of 62.2-61.0 years. Funnel plot analysis documented heterogeneity in studies which combined cancers and benign diseases. Our meta-analysis demonstrated a significant difference in favor of laparoscopic procedures regarding costs and operating time (standardized mean difference (SMD) 0.686 and 0.493) and in favor of robotic surgery concerning morbidity rate (odds ratio (OR) 0.763), although no benefits were documented when analyzing exclusively randomized trials. When we differentiated approaches by side of resections, a significant difference was found in favor of the laparoscopic group when analyzing operating time in left-sided and pelvic procedures (SMD 0.609 and 0.529) and blood loss in pelvic resections (SMD 0.339).

CONCLUSION

Laparoscopic techniques were documented as the shorter procedures, which provided lower blood loss in pelvic resections, while morbidity rate was more favorable in robotic surgery. However, these results could not be confirmed when we focused the analysis on randomized trials only.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Current State of Laparoscopic Colonic Surgery in Austria: A National Survey

PURPOSE

Several studies have demonstrated that laparoscopic colonic resection has significant benefits in comparison with open approaches in patients with benign and malignant disease. The proportion of colonic and rectal resections conducted laparoscopically in Austria is not currently known; the aim of this study was to evaluate the current status of laparoscopic colonic surgery in Austria.

MATERIALS AND METHODS

A questionnaire was distributed to all general surgical departments in Austria. In collaboration with IMAS, an Austrian market research institute, an online survey was used to identify laparoscopic and open colorectal resections performed in 2013. The results were compared with data from the National Hospital Morbidity Database (NHMD), in which administrative in-patient data were also collected from all general surgical departments in Austria in 2013.

RESULTS

Fifty-three of 99 surgical departments in Austria responded (53.5%); 4335 colonic and rectal resections were carried out in the participating departments, representing 50.5% of all NHMD-recorded colorectal resections (n = 8576) in Austria in 2013. Of these 4335 colonic and rectal resections, 2597 (59.9%) were carried out using an open approach, 1674 (38.6%) were laparoscopic, and an exact classification was not available for 64 (1.5%). Among the NHMD-recorded colonic and rectal resections, 6342 (73.9%) were carried out with an open approach, and 2234 (26.1%) were laparoscopic.

CONCLUSIONS

The proportion of colorectal resections that are carried out laparoscopically is low (26.1%). Technical challenges and a learning curve with a significant number of cases may be reasons for the slow adoption of laparoscopic colonic surgery.

Elective Laparoscopic Cholecystectomy – Is It Safe In The Hands Of Residents During Training?

was to assess safety of elective laparoscopic cholecystectomy (LC) performed by residents that are undergoing training in general surgery.

. A retrospective analysis was conducted on 330 patients operated electively due to cholelithiasis. Patients with acute cholecystitis, choledocholithiasis, undergoing cholecystec-tomy as a part of more extensive operation and patients with gall-bladder cancer were excluded. Group 1 included patients operated by resident, group 2 – by specialist. Duration of operation, mean blood loss, number of major complications, number of conversions to the open technique and conversions of the operator, reoperations and length of hospital stay were analyzed.

Mean operative time overall was 81 min (25 – 170, SD±28.6) and 71 min (30-210, SD±29.1) in groups 1 and 2 respectively (p=0.00009). Mean blood loss in group 1 was 45±68.2 ml and in group 2 – 41±73.4 ml (p=0.23). Six major complications has occurred (1.81%) – 2 (2%) in group 1 and 4 (1.7%) in group 2. 18 cases (15.5%) of conversion of the operator occurred in group 1, and 6 cases (2.6%) of conversion of the operator happened in group 2. Average LOS was 1.9 days in group 1 and 2.3 days in group 2 (p=0.03979).

Elective LC performed by a supervised resident is a safe procedure. Tactics of “conversion of operator” allowed to prevent major complications. Longer LC by residents is natural during the learning curve. Modifications of residency program in the field of laparoscopy may increase its accessibility.

[Treatment reality with respect to laparoscopic surgery of colonic cancer in Germany]

BACKGROUND

Prospective randomized studies and meta-analyses have shown that laparoscopic resection for colonic cancer is equivalent to open resection with respect to the oncological results and has short-term advantages in the early postoperative outcome. The aim of this study was to investigate whether laparoscopic colonic resection has become established as the standard in routine treatment.

METHODS

Data from the multicenter observational study "Quality assurance colonic cancer (primary tumor)" from the time period from 1 January 2009 to 21 December 2011 were evaluated with respect to the total proportion of laparoscopic colonic cancer resections and tumor localization and specifically for laparoscopic sigmoid colon cancer resections. A comparison between low and high volume clinics (< 30 versus ≥ 30 colonic cancer resections/year) was carried out.

RESULTS

Laparoscopic colonic cancer resections were carried out in 12 % versus 21.4 % of low and high volume clinics, respectively (p < 0.001) with a significant increase for low volume clinics (from 8.0 % to 15.6 %, p < 0.001) and a constant proportion in high volume clinics (from 21.7 % to 21.1 %, p = 0.905). For sigmoid colon cancer laparoscopic resection was carried out in 49.7 % versus 47.6 % (p = 0.584). Differences were found between low volume and high volume clinics in the conversion rates (17.3 % versus 6.6 %, p < 0.001), the length of the resected portion (Ø 23.6 cm versus 36.0 cm, p < 0.001) and the lymph node yield (Ø n = 15.7 versus 18.2, p = 0.008). There were no differences between the two groups of clinics regarding postoperative morbidity and mortality. The postoperative morbidity and length of stay were significantly lower for laparoscopic sigmoid resection than for conventional sigmoid resection.

CONCLUSION

The laparoscopic access route for colonic cancer resection is not the standard approach in the participating clinics. The laparoscopic access route has the highest proportion for sigmoid colon resection. The differences in the conversion rates, length of the resected portion and the number of lymph nodes investigated between the low volume and high volume clinics must be viewed critically and must be interpreted in connection with the long-term oncological results.