Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC).

METHODS

A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures.

RESULTS

Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045).

CONCLUSIONS

Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

Longitudinal Analysis of Local Recurrence and Survival After Transanal Abdominal Transanal Radical Proctosigmoidectomy for Low Rectal Cancer Treated With Neoadjuvant Chemoradiation Therapy

BACKGROUND

The transanal abdominal transanal radical proctosigmoidectomy was developed in 1984 as a sphincter preservation surgery in patients with low rectal cancers after preoperative radiation therapy. While serving as a catalyst for disruptive sphincter preservation surgery, it continues to be used and evolve. With the controversy over safety and local recurrence in other sphincter-preserving surgery, review of transanal abdominal transanal radical proctosigmoidectomy long-term oncologic outcomes is warranted.

OBJECTIVE

To assess local recurrence and survival after transanal abdominal transanal radical proctosigmoidectomy after neoadjuvant chemoradiation therapy.

DESIGN

Retrospective cohort study of a prospectively maintained database.

SETTINGS

Tertiary rectal cancer referral center.

PATIENTS

Patients with low adenocarcinoma (≤5 cm anorectal ring) receiving neoadjuvant chemoradiation therapy and then transanal abdominal transanal radical proctosigmoidectomy for curative resection between 1998 and 2021.

MAIN OUTCOME MEASURES

Local recurrence rates and overall survival rates.

RESULTS

Of 255 included patients, 67.8% were men (n = 173); the mean age was 58.7 years (SD 11.5) and the mean BMI was 27.1 (SD 5.4), with 50.2% (n = 128) having ASA class II and 49.8% (n = 127) having ASA class III/IV. The mean tumor size was 4.8 cm (SD 1.9), the majority of patients had clinical T3 disease (81.8%; n = 184), and 52.1% had nodal disease (n = 100). The median radiation dose was 5400 cGy, with 73.7% (n = 149) achieving good response and 90.2% (n = 230) receiving minimally invasive surgery. The complete total mesorectal excision rate was 94.3%, and 100% of patients (n = 255) had negative distal margins. The mean number of examined lymph nodes were 13.9 (SD 10.7). After a median follow-up of 55.4 months, 5.1% of patients (n = 13) developed local recurrence at a median time of 29.6 months. The 5-year overall survival was 84.1% (95% CI, 78.8-89.4).

LIMITATIONS

Retrospective review with risk of bias and lack of generalizability.

CONCLUSIONS

In this longitudinal study, the transanal abdominal transanal radical proctosigmoidectomy demonstrated excellent long-term locoregional control and survival in very low rectal cancers. The superior transanal abdominal transanal radical proctosigmoidectomy outcomes are durable over time, warranting expansion of the sphincter-preserving surgery technique. See Video Abstract .

ANLISIS LONGITUDINAL DE LA RECURRENCIA LOCAL Y LA SUPERVIVENCIA DESPUS DE LA PROCTOSIGMOIDECTOMA RADICAL TRANSANAL ABDOMINAL TATA PARA EL CNCER DE RECTO BAJO TRATADO CON QUIMIORRADIACIN NEOADYUVANTE

ANTECEDENTES:La proctosigmoidectomía radical transanal abdominal se desarrolló en 1984 como una cirugía de preservación del esfínter en cánceres de recto bajo después de la radiación preoperatoria. Si bien sirve como catalizador para la cirugía disruptiva de preservación del esfínter, continúa utilizándose y evolucionando. Con la controversia sobre la seguridad y la recurrencia local en otras cirugías que preservan el esfínter, se justifica la revisión de los resultados oncológicos a largo plazo de la proctosigmoidectomía radical transanal abdominal.OBJETIVO:Evaluar localmente después de Proctosigmoidectomía Radical Transanal Abdominal Transanal después de quimiorradiación neoadyuvante.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida de forma prospectiva.AJUSTES:Centro terciario de referencia para el cáncer de recto.PACIENTES:Adenocarcinoma bajo (=/ Collapse

Key Words Collapse

MESH Headings

• Humans
• Male
• Middle Aged
• Female
• Retrospective Studies
• Longitudinal Studies
• Neoadjuvant Therapy
• Rectal Neoplasms/surgery
• Adenocarcinoma/therapy
• Adenocarcinoma/pathology
• Neoplasm Staging

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Grants Collapse

Affiliation(s)

John H Marks Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
Thais Reif de Paula
Hela Saidi
Taylor P Ikner
Henry Schoonyoung
Gerald Marks
Deborah S Keller

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The robotic NICE procedure outperforms conventional laparoscopic extracorporeal-assisted colorectal resection: results of a matched cohort analysis

INTRODUCTION

We introduced the robotic NICE procedure for left-sided colorectal resection in 2018 in which the entire procedure is performed without loss of pneumoperitoneum and without an abdominal wall incision by performing natural orifice-assisted transrectal extraction of the specimen and intracorporeal anastomosis. We compare the results of the NICE procedure versus conventional laparoscopic resection, which was our standard approach prior to 2018.

METHODS

A matched pair case-control study compared patients following the NICE procedure versus those who underwent laparoscopic left-sided colorectal resection with conventional extracorporeal-assisted technique. Cases were performed at an Academic Medical Center and recorded in a prospective database to analyze perioperative outcomes.

RESULTS

From a total cohort of 352 patients, 83 were matched in each group. When comparing the NICE procedure vs. the Extracorporeal-Assisted laparoscopic group, there were no significant differences in age (58.5 vs. 59.3 years old), sex (47 vs. 42 Female), body mass index (27.4 vs. 27.5 kg/m2), ASA, diagnosis, or type of surgery. Operative time (198.8 vs. 197.7 min), blood loss (56.0 vs. 53.3 ml), intraoperative complications (0.0% vs. 0.0%), and conversion rates (0.0% vs. 0.0%) were similar in both groups. The NICE procedure was associated with significantly earlier return of bowel function (40.7 vs. 23.6 h), shorter length of stay (3.1 vs. 2.2 days), and lower total opioid use (94.6 vs. 70.5 morphine milligram equivalents). Overall, there were no differences in postoperative abscess formation, complications, readmission, or reoperation rates.

CONCLUSION

When compared to conventional laparoscopic resection, the NICE procedure is associated with short-term benefits including earlier recovery and less opioid use without increased operative time or increased risk of complications. Multicenter studies are recommended to validate benefits and limitations of this technique.

A national evaluation of adjuvant chemotherapy in pT4N0M0 colon cancer from the National Cancer Database

BACKGROUND

T stage is a prognostic biomarker for overall survival in colon cancer and pathologic T4 disease is a high-risk characteristic. Adjuvant chemotherapy is recommended to improve overall survival in pT4N0M0, but compliance with guidelines is unknown. We aimed to evaluate adjuvant chemotherapy use and impact on overall survival in pT4N0M0 colon cancer.

METHODS

The National Cancer Database was reviewed for pT4N0M0 colon adenocarcinomas undergoing curative surgical resection (2010-2017). Cases were stratified into no adjuvant chemotherapy and adjuvant chemotherapy cohorts. Moderated multiple regression assessed factors associated with no AC. Kaplan-Meier and Cox regression assessed overall survival in propensity-score matched cohorts. The main outcome measures were adjuvant chemotherapy use, factors associated with adjuvant chemotherapy, and impact on overall survival.

RESULTS

Of 11 847 cases, 62.4% (n = 7391) received no adjuvant chemotherapy. With private insurance, comorbidities or income do not affect adjuvant chemotherapy use. Medicare cases with a Charlson-Deyo comorbidity index of 0 (odds ratio [OR] = 0.861, 95% confidence interval [CI] = 0.760 to 0.975; P = .019) and Medicare payors with high income (OR = 0.813, 95% CI = 0.690 to 0.959; P = .014) were associated with adjuvant chemotherapy. Medicaid Charlson-Deyo comorbidity index 0 (OR = 1.374, 95% CI = 1.125 to 1.679; P = .002) and uninsured Charlson-Deyo comorbidity index 0 (OR = 1.351, 95% CI = 1.120 to 1.629; P = .002) were associated with no adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved 5-year overall survival (71.7% vs 56.4%; P < .001; adjusted hazard ratio = 0.543, 95% CI = 0.499 to 0.590; P < .001).

CONCLUSION

Although adjuvant chemotherapy is associated with improved overall survival, compliance is low. There is a complex relationship between payor, income, comorbidity, and adjuvant chemotherapy receipt. Medicare patients with no comorbidities or higher income have better adjuvant chemotherapy use. With private insurance, adjuvant chemotherapy compliance is not affected by comorbidities or income, whereas Medicaid and uninsured patients with no comorbidities have poor compliance. Future work could target these disparities for equitable care.

A prospective phase II clinical trial/IDEAL Stage 2a series of single-port robotic colorectal surgery for abdominal and transanal cases

AIM

Slow laparoscopy adoption accelerated the uptake of robotic surgery. However, the current robotic platforms have limitations in transanal applications and multiple port sites. The da Vinci single-port (SP) robot is currently used on trial for colorectal surgery, and broad assessment of outcomes is needed. We aimed to report findings of a phase II clinical trial of SP robotic colorectal surgery.

METHODS

A sequentially reported prospective case series was performed on patients using SP robotics at a tertiary referral centre from 1 October 2018 to 31 August 2021. Cases were stratified into abdominal and transanal cohorts. Demographics, intra-operative variables and 30-day postoperative outcomes were evaluated. Univariate analysis was performed, with statistical process control for the docking process. Main outcomes were conversion rates, morbidity, mortality and point of standardization of docking.

RESULTS

In all, 133 patients were included: 93 (69.92%) abdominal and 40 (30.08%) transanal. The main diagnosis was rectal cancer (n = 59) and the procedure performed a robotic transanal abdominal transanal radical proctosigmoidectomy (n = 30). There were no conversions to open surgery. Two abdominal (2.15%) and three transanal cases (7.50%) were converted to laparoscopy. All colorectal adenocarcinomas had negative margins, proper lymph node harvest and complete mesorectal excision, as appropriate. Docking became a standardized process at cases 34 (abdominal) and 23 (anorectal). After surgery, bowel function returned on mean day 2 (abdominal) and 1 (transanal). The morbidity rate was 15.05% (abdominal) and 27.50% (transanal). There were two major morbidities in each cohort. Overall, there were three (2.65%) readmissions, one reoperation and no mortality.

CONCLUSIONS

Single-port robotics is feasible for all types of colorectal procedures, with good clinical and oncological outcomes. With this development in colorectal surgery, further studies can develop best practices with this novel technology.

Factors Associated With Adjuvant Chemotherapy Noncompliance and Survival in Older Adults With Stage III Colon Cancer

BACKGROUND

Standard management of stage III colon cancer includes surgical resection and adjuvant chemotherapy. Despite improved overall survival with adjuvant chemotherapy in stage III colon cancer, it is reportedly underused in older adults. To date, no contemporary national analysis of adjuvant chemotherapy use and its impact on older adults with stage III colon cancer exists.

OBJECTIVE

This study aimed to assess the current use of adjuvant chemotherapy in older adults with stage III colon cancer and determine factors associated with noncompliance.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted using the National Cancer Database.

PATIENTS

This study included patients aged 65 years and older undergoing curative resection for stage III colon adenocarcinomas, 2010-2017.

MAIN OUTCOME MEASURES

Adjuvant chemotherapy use, factors associated with adjuvant chemotherapy use, and overall survival with and without adjuvant chemotherapy in older adults with pathologic stage III disease.

RESULTS

Of 64,608 patients included, 64.3% received adjuvant chemotherapy. Adjuvant chemotherapy was significantly independently associated with improved 1-, 3-, and 5-year overall survival vs no adjuvant chemotherapy (92.8%, 75.3%, 62.4% vs 70.8%, 46.6%, 32.7%; HR 0.475; 95% CI, 0.459-0.492; p <0.001). Compared with the no adjuvant chemotherapy cohort, patients who received adjuvant chemotherapy were younger, female, and less comorbid ( p < 0.001). Factors associated with adjuvant chemotherapy noncompliance included advancing age, lower annual income, open approach, longer length of stay, pathologic stage IIIA, and fewer than 12 lymph nodes.

LIMITATIONS

Administrative data source with inherent risks of bias, coding errors, and limitations in the fields available for analysis.

CONCLUSIONS

Adjuvant chemotherapy significantly improved overall survival but was only used in 64.3% of older adults with stage III colon cancer. Adjuvant chemotherapy noncompliance was seen in the most vulnerable and highest-risk patients, including those with greater comorbidity, lower income, and patients who received open surgery. See Video Abstract at http://links.lww.com/DCR/C125 .

FACTORES ASOCIADOS CON EL INCUMPLIMIENTO DE LA QUIMIOTERAPIA ADYUVANTE Y LA SUPERVIVENCIA EN ADULTOS MAYORES CON CNCER DE COLON EN ESTADIO III

ANTECEDENTES: El tratamiento estándar de oro del cáncer de colon en estadio III incluye la resección quirúrgica y la quimioterapia adyuvante. A pesar de la mejora de la supervivencia general con la quimioterapia adyuvante en el cáncer de colon en estadio III, se reporta que se utiliza poco en los adultos mayores. Hasta la fecha, no existe ningún análisis nacional actual, sobre el uso de quimioterapia adyuvante y su impacto en adultos mayores con cáncer de colon en etapa III.OBJETIVO: Evaluar el uso actual de quimioterapia adyuvante en adultos mayores con cáncer de colon en estadio III y determinar los factores asociados con el incumplimiento.DISEÑO: Estudio de cohorte retrospectivo.AJUSTES: Realizado y utilizando la Base de Datos Nacional de Cáncer.PACIENTES: Pacientes de 65 años o más sometidos a resección curativa por adenocarcinomas de colon en estadio III de 2010-2017.PRINCIPALES MEDIDAS DE RESULTADO: Uso de quimioterapia adyuvante, factores asociados con el uso de quimioterapia adyuvante y supervivencia general con y sin quimioterapia adyuvante en adultos mayores con enfermedad en estadio patológico III.RESULTADOS: De 64.608 pacientes incluidos, el 64,3% recibió quimioterapia adyuvante. La quimioterapia adyuvante se asoció de forma significativa e independiente con una mejor supervivencia general a 1, 3 y 5 años frente a ninguna quimioterapia adyuvante (92,8 %, 75,3 %, 62,4 % frente a 70,8 %, 46,6 %, 32,7 %; respectivamente, HR 0,475, 95 % IC 0,459-0,492, p < 0,001). En comparación con la cohorte sin quimioterapia adyuvante, los pacientes que recibieron quimioterapia adyuvante eran más jóvenes, mujeres y con menos comorbilidad. (p < 0,001). Los factores asociados con el incumplimiento de la quimioterapia adyuvante incluyeron edad avanzada (OR 0,857, IC del 95 % 0,854-0,861), ingresos anuales más bajos (OR 0,891, IC del 95 % 0,844-0,940), abordaje abierto (0,730, IC del 95 % 0,633-0,842), mayor duración de la estancia (OR 0,949, IC 95% 0,949-0,954) y estadio patológico IIIA (0,547, IC 95% 0,458-0,652) y <12.LIMITACIONES: Fuente de datos administrativos con riesgos inherentes de sesgo, errores de codificación y limitaciones en los campos disponibles para el análisis.CONCLUSIONES: La quimioterapia adyuvante mejoró significativamente la supervivencia general, pero solo se utilizó en el 64,3 % de los adultos mayores con cáncer de colon en estadio III. El incumplimiento de la quimioterapia adyuvante se observó en los pacientes más vulnerables y de mayor riesgo, incluidos aquellos con mayor comorbilidad, menores ingresos y pacientes que recibieron cirugía abierta. Consulte Video Resumen en http://links.lww.com/DCR/C125 . (Traducción-Dr. Fidel Ruiz Healy ).

Success rates and outcomes of the robotic NICE procedure across complicated and uncomplicated diverticulitis cases

INTRODUCTION

We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis.

METHODS

Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications.

RESULTS

Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578).

CONCLUSION

Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

BACKGROUND

The Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.

METHODS

Consecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.

RESULTS

A total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.

CONCLUSION

The NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

Colorectal cancer in the 45-to-50 age group in the United States: a National Cancer Database (NCDB) analysis

BACKGROUND

Amid increasing awareness of early-onset colorectal cancer (CRC), guidelines in the United States (US) recently lowered the recommended routine CRC screening age from 50 to 45 in average-risk individuals. There are little data on the number of patients in this age group diagnosed with CRC prior to these changes. Our objective was to audit the historic CRC case trends and impact of CRC in the 45-to-50-year-old category prior to new screening recommendations.

METHODS

Colorectal adenocarcinoma cases in 45-to-50-year-old patients were queried from the NCDB (2004-2017). Cases were stratified by sex, race, and site. The disability-adjusted lost years (DALY) and lost earnings were estimated. The average annual percentage changes (AAPC) of CRC incidence were estimated using jointpoint analysis. The main outcome measures were DALY and lost earnings. Secondary outcome measures were the 2004-2017 AAPC and the cumulative incidence of potential CRC cases in the 45-to-50 cohort through 2030 without guideline changes.

RESULTS

67,442 CRC patients in the 45-to-50 demographic were identified. The CRC burden resulted 899,905 DALY and $17 billion in lost earnings. The 2004-2017 AAPC was 1.6%, with an estimated 13-year increase of 25%. There were sex-, race-, and anatomic site-specific discrepancies with estimated 13-year increases of 30% for males, 110% for American Indian/ Alaska Natives/ Asian American/ Pacific Islander races, and 31% for rectal cancer by 2030.

CONCLUSION

CRC has been steadily increasing in the 45-to-50 age group, with tremendous disability and cost ensuing. There is great potential benefit from lowering the recommended routine CRC screening age to 45. Targeted intervention could ensure the most vulnerable segments benefit from the new guidelines, in both reducing the incidence and improving survivorship in CRC patients.

Needs assessment for patient-centered education and outcome metrics in robotic surgery

BACKGROUND

From clinical experience, many patients undergoing robotic assisted surgery (RAS) have a poor understanding of the technology. To ensure informed consent and appropriate expectations, a needs assessment for patient-centered education and outcome metrics in RAS is warranted. Our goal was to perform an assessment of patient understanding, comfort with robotic technology, and ability to obtain critical information from their surgeon when undergoing RAS.

METHODS

Twenty patients planned for RAS by three surgeons were asked to complete a six-item Likert agreement scale survey prior to signing informed consent. The study coordinator administered surveys, while the surgeon left the room. Indicator statements were crafted to reduce bias and two-way evaluated for consistency. The surgeons were additionally asked their perception of each patient's understanding and comfort with RAS. Frequency statistics and tendencies were analyzed.

RESULTS

Surgeons strongly agreed all patients appropriately understood how RAS functioned and would ask more questions before signing consent, if needed. Patients were predominately not familiar with RAS and felt surgeons did not explain how RAS worked. There was wide variability on if patients understood how RAS worked for their treatment. Overall, patients were not completely comfortable with RAS for their care, did not understand the risks of RAS compared to other approaches, and did not feel their surgeon understood what they needed to know to make informed decisions.

CONCLUSIONS

This needs assessment demonstrated critical gaps in patient knowledge about RAS, surgeon communication skills, and the ability of surgeons to know what was important from the patient perspective. The development of RAS patient-centered education and outcome metrics could help address these gaps.

A Randomized Controlled Trial Examining the Impact of an Anorectal Surgery Multimodal Enhanced Recovery Program on Opioid Use

BACKGROUND

Anorectal cases may be a common gateway to the opioid epidemic. Opioid reduction is inherent in enhanced recovery after surgery (ERAS) protocols, but little work has evaluated ERAS in these cases.

OBJECTIVE

To determine if ERAS could reduce postoperative opioid utilization in ambulatory anorectal surgery without sacrificing patient pain or satisfaction.

METHODS

A randomized controlled trial assigned ambulatory anorectal patients to ERAS (experimental) or routine care (surgeon's choice) for pain management (control) over 30-days postoperatively. Primary outcome was overall days of opioid use. Secondary outcomes included pain and satisfaction scores over multiple time points and new persistent opioid use. The Visual Analog Scale, Functional Pain Scale, and EQ-5D-3L measured patient-reported pain and satisfaction. Univariate analysis compared outcomes overall and at individual time points. Two-way mixed ANOVA evaluated pain and satisfaction measures between groups and over time.

RESULTS

Thirty-two patients were randomized into each arm (64 total). The control group consumed significantly more opioids after discharge (median 121.3MME vs 23.5MME, P < 0.001). Significantly more control patients requested additional narcotics (P  =  0.004), made unplanned calls (P = 0.009), and had unplanned clinic visits (P = 0.003). The control group had significantly more days on opioids (mean 14.4 vs 2.2, P < 0.001). Three control patients (9.4%) versus no experimental patients had new persistent opioid use. The mean global health, EQ5D-3L, Visual Analog Scale, and Functional Pain scores were comparable between groups over time.

CONCLUSIONS

An ERAS protocol in ambulatory anorectal surgery is feasible, and resulted in reduced opioid use, and healthcare utilization, with no difference in pain or patient satisfaction. This challenges the paradigm that extended opioids are needed for effective postoperative pain management.

A national evaluation of the use and survival impact of adjuvant chemotherapy in Stage II colon cancer from the national cancer database

AIM

Stage II colon cancers are a heterogeneous category, with controversy over use of adjuvant chemotherapy (AC). Patients with high-risk features may benefit from AC to improve overall survival (OS). Current guidelines do not routinely recommend AC in low-risk cases, but the actual use and benefit on OS in this cohort have not been fully examined on a national scale. We aimed to evaluate the use and impact of AC on OS in low-risk Stage II colon cancer.

METHODS

The national cancer database was reviewed for Stage II colon cancers undergoing curative resection (2010-2015). Cases with preoperative radio-chemotherapy or high-risk features were excluded. Cases were stratified into 'AC' and 'no AC' cohorts, and then propensity score matched. Kaplan-Meier and Cox regression analysed OS. The main outcome measures were the incidence and impact of AC on OS in low-risk Stage II colon cancer.

RESULTS

Of 39 926 patients evaluated, 8.2% (n = 3275) received AC. Matching resulted in 3275 cases per cohort. AC significantly improved 1-, 3- and 5-year OS versus no AC (P = 0.0017). The 5-year absolute risk reduction was 2.6%, relative risk reduction 12%, with a number needed to treat of 38. In the Cox model, AC remained significantly associated with increased OS (hazard ratio 0.816; 95% CI 0.713-0.934; P < 0.003).

CONCLUSIONS

From this dataset, AC was associated with improved OS in low-risk Stage II disease. These findings from a large-scale sample question current guidelines and the need for better risk stratification. Further study with more robust variables is warranted to determine AC best practices.

National disparities in use of minimally invasive surgery for rectal cancer in older adults

BACKGROUND

Minimally invasive surgery (MIS) is safe and improves outcomes in older persons with rectal cancer but may be underutilized. As older persons are the largest surgical population, investigation of the current use and factors impacting MIS use is warranted. Our goal is to investigate the trends and disparities that affect utilization of MIS in older persons with rectal cancer.

METHODS

The National Cancer Database was reviewed for persons 65 years and older who underwent curative resection for rectal adenocarcinoma from 2010 to 2017. Cases were stratified by surgical approach (open or MIS [laparoscopic or robotic]). Univariate analysis compared patient and provider demographics across approaches. Multivariate analysis investigated variables associated with MIS use. Main outcome measures were trends and factors associated with MIS use in older persons.

RESULTS

Of 31,910 patients analyzed, 51.9% (n = 16,555) were open and 48.1% (n = 15,355) MIS. The MIS cohort was 66.7% (n = 10,236) laparoscopic and 33.3% (n = 5119) robotic. MIS increased from 29% in 2010 (n = 1197; 25% laparoscopic, 4% robotic) to 65% in 2017 (n = 2382; 35% laparoscopic, 30% robotic), likely from annual increases in robotics (OR 1.24/year, p < 0.0001). In the unadjusted analysis, there were significant differences in MIS use by age, race, comorbidity, socioeconomic status, and facility type. In multivariate analysis, patients with advancing age (OR 0.93, p < 0.001), major comorbidity (OR 0.75, p < 0.001), total proctectomy (OR0.78, p < 0.001), and advanced pathologic stage (OR 0.51, p < 0.001) were less likely to undergo MIS.

CONCLUSION

Nationwide, less than half of rectal cancer cases in older persons were performed with MIS, despite steady robotic growth. Patient and facility factors impacted MIS use. Further work on regionalizing rectal cancer care and ensuring equitable MIS access and training could improve utilization.

Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database

BACKGROUND

Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States.

OBJECTIVE

The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted using the National Cancer Database, 2011-2016.

PATIENTS

Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included.

MAIN OUTCOME MEASURES

Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured.

RESULTS

Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028).

LIMITATIONS

This was a retrospective cohort study with limited variables available for analysis.

CONCLUSIONS

Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584.

PREDICTORES PARA UN MARGEN POSITIVO DE RESECCIN CIRCUNFERENCIAL EN EL CNCER DE RECTO UNA AUDITORA VIGENTE DE LA BASE DE DATOS NACIONAL DE CANCER

ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.

N1c colon cancer and the use of adjuvant chemotherapy: a current audit of the National Cancer Database

AIM

Colorectal cancer staging has evolved to define N1c as the presence of tumour deposits without concurrent positive lymph nodes. Work to date reports poor prognosis in N1c colon cancer, with Stage III categorization and adjuvant chemotherapy (AC) recommended. No study has yet evaluated the prevalence, treatment compliance or treatment-related outcomes on a national scale. We aimed to evaluate the prevalence of N1c colon cancer, use, outcomes and factors associated with AC in the USA.

METHOD

The National Cancer Database was reviewed for N1cM0 colon adenocarcinomas that underwent resection from 2010 to 2016. Cases were stratified into 'AC' or 'no AC' cohorts. The Kaplan-Meier method was used to estimate overall survival (OS) and compare the AC and no AC cohorts using the log-rank test. Multivariable logistic regression identified factors associated with AC. The main outcome measures were the prevalence and factors associated with AC use and its impact in N1c disease.

RESULTS

Of the 5684 (1.59% of 357 752) colon adenocarcinomas that were N1c, 55% (n = 3071) received AC. AC significantly improved 1-, 3- and 5-year OS compared with no AC (96.2%, 80%, 67.4% and 72.9%, 48.5%, 33.8%, respectively; P < 0.001). Compared with the no AC group, AC patients were younger, had less comorbidity, were of the male gender and received minimally invasive surgery at an academic treatment centre (all P < 0.05). Socioeconomic and procedural factors significantly impacted the use of AC.

CONCLUSION

In the USA, AC is underutilized in N1c colon cancer despite significantly improved OS. Socioeconomic and procedural factors associated with AC were identified, highlighting disparities in AC use and opportunities to improve oncological outcomes and survival.

Management of the positive pathologic circumferential resection margin in rectal cancer: A national cancer database (NCDB) study

BACKGROUND

The circumferential resection margin (CRM) is a primary predictor of local recurrence and survival in rectal cancer, and an important consideration in guiding treatment. CRM is usually predicted preoperatively, so optimal management of an unexpected pathologic positive CRM involvement is debatable. We aimed to investigate the postoperative management of T3N0 rectal cancers with a positive pathologic CRM, and the impact of each strategy on survival.

METHODS

The NCDB was reviewed for pathological T3N0 rectal cancer cases from 2010 to 2015, that received neoadjuvant chemotherapy, had surgical resection with pathological clear margins, but a positive pathologic CRM(disease≤2 mm from radial margin). The main outcomes were the incidence, treatment modalities used, and impact of each modality on survival. Univariate analysis evaluated the demographic and provider characteristics across treatment groups. Kaplan-Meier and Cox regression analysis assessed survival and factors associated with overall survival (OS).

RESULTS

Of 1607 cases with a positive CRM, 65% (1045) received no adjuvant treatment and 35% (n = 562) received adjuvant chemotherapy (AC). After matching, the 1-, 3-, and 5-year OS rates were 98.5%, 88.6% and 76.6% for AC and 96.9%, 84.6% and 68.4% for with no treatment (p = .027). Factors independently associated with improved OS were treatment at an academic/research facility (p = .009), minimally invasive approach (p = .005), well and moderately differentiated tumor (p < .001), absence of perineural invasion (p = .015) and AC administration (p = .047).

CONCLUSION

In T3N0 rectal cancers resected with local clear margins but a positive pathologic CRM, AC improved OS. However, only a third received this option. Further study is needed to investigate the disparities in AC use in these patients with unexpected pathologic results.

Statistical Process Control (SPC) to drive improvement in length of stay after colorectal surgery

BACKGROUND

Novel quality improvement(QI) methods are needed to optimize healthcare costs and value. Our goal was to determine if Statistical Process Control(SPC), an industrial QI tool, could transform length of stay(LOS) into a process measure, identify outliers, and their impact on surgical outcomes.

METHODS

SPC was performed on an institutional colorectal resection database 1/1/13-5/1/2018 to identify outliers and compare outcome variables across outliers and non-outliers. Control charts analyzed the process performance of LOS over time. Control limits were set at ± 1 standard deviation(SD) from the mean. Measures were stable within these limits.

RESULTS

LOS was stable, with consistent annual rates and variation of outliers. Outliers had identifiable causes of variation that were significantly different from non-outliers(p < 0.05). The variation resulted in more complications, readmissions, and reoperations in outliers(p < 0.05).

CONCLUSIONS

SPC can be applied to LOS, a stable process measure with decreasing variability over time, and easy outlier identification. Identifying outliers can facilitate targeted quality improvement.