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English NC, Ivankova NV, Smith BP, Jones BA, Herbey II, Rosamond B, Kim DH, Oslock WM, Schoenberger-Godwin YMM, Pisu M, Chu DI. Providers' and survivors' perspectives on the availability and accessibility of surgery in gastrointestinal cancer care. J Gastrointest Surg 2024; 28:1330-1338. [PMID: 38824070 PMCID: PMC11298309 DOI: 10.1016/j.gassur.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Surgery is essential for gastrointestinal (GI) cancer treatment. Many patients lack access to surgical care that optimizes outcomes. Scarce availability and/or low accessibility of appropriate resources may be the reason for this, especially in economically disadvantaged areas. This study aimed to investigate providers' and survivors' perspectives on barriers and facilitators to the availability and accessibility of surgical care. METHODS Semistructured interviews informed by surgical disparities and access-to-care conceptual frameworks with purposively selected GI cancer providers and survivors in Alabama and Mississippi were conducted. Survivors were within 3 years of diagnosis of stage I to III esophageal, pancreatic, or colorectal cancer. Transcripts were analyzed using inductive thematic and content analysis techniques. Intercoder agreement was reached at 90 %. RESULTS The 27 providers included surgeons (n = 11), medical oncologists (n = 2), radiation oncologists (n = 2), a primary care physician (n = 1), nurses (n = 8), and patient navigators (n = 3). This study included 36 survivors with ages ranging from 44 to 87 years. Of the 36 survivors, 21 (58.3 %) were male, and 11 (30.6 %) identified as Black. Responses were grouped into 3 broad categories: (i) transportation/geographic location, (ii) specialized care/testing, and (iii) patient-/provider-related factors. The barriers included lack and cost of transportation, reluctance to travel because of uneasiness with urban centers, low availability of specialized care, overburdened referral centers, provider-related referral biases, and low health literacy. Facilitators included availability of charitable aid, centralizing multidisciplinary care, and efficient appointment scheduling. CONCLUSION In the Deep South, barriers and facilitators to the availability and accessibility of GI surgical cancer care were identified at the health system, provider, and patient levels, especially for rural residents. Our data suggest targets for improving the use of surgery in GI cancer care.
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Affiliation(s)
- Nathan C English
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General Surgery, University of Cape Town, Cape Town, South Africa
| | - Nataliya V Ivankova
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Burkely P Smith
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bayley A Jones
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ivan I Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brendan Rosamond
- Department of General Surgery, Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, TX, United States
| | - Dae Hyun Kim
- Department of Health Management and Policy, Georgetown University, DC, United States
| | - Wendelyn M Oslock
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of Quality, Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States
| | - Yu-Mei M Schoenberger-Godwin
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maria Pisu
- Division of Preventive Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Oshio H, Konta T, Oshima Y, Yunome G, Okazaki S, Kawamura I, Ashitomi Y, Kawai M, Musha H, Motoi F. Learning curve of robotic rectal surgery using risk-adjusted cumulative summation: a 5-year institutional experience. Langenbecks Arch Surg 2023; 408:89. [PMID: 36786889 DOI: 10.1007/s00423-023-02829-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Outline learning phases of robot-assisted laparoscopic surgery for rectal cancer and compare surgical and clinical outcomes between each phase of robot-assisted laparoscopic surgery and the mastery phase of conventional laparoscopic surgery. METHODS From 2015 to 2020, 210 patients underwent rectal cancer surgery at Sendai Medical Center. We performed conventional laparoscopic surgery in 110 patients and, laparoscopic surgery in 100 patients. The learning curve was evaluated using the cumulative summation method, risk-adjusted cumulative summation method, and logistic regression analysis. RESULTS The risk-adjusted cumulative summation learning curve was divided into three phases: phase 1 (cases 1-48), phase 2 (cases 49-80), and phase 3 (cases 81-100). Duration of hospital stay (13.1 days vs. 18.0 days, respectively; p = 0.016) and surgery (209.1 min vs. 249.5 min, respectively; p = 0.045) were significantly shorter in phase 3 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group. Blood loss volume was significantly lower in phase 1 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group (17.7 ml vs. 79.7 ml, respectively; p = 0.036). The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopic surgery group (p = 0.0131). CONCLUSIONS Robot-assisted laparoscopic surgery for rectal cancer was safe and demonstrated better surgical and clinical outcomes, including a shorter hospital stay, less blood loss, and a shorter surgical duration, than conventional laparoscopic surgery. After experience with at least 80 cases, tactile familiarity can be acquired from visual information only (visual haptic feedback). CLINICAL TRIAL REGISTRATION UMIN reference no. UMIN000019857.
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Affiliation(s)
- Hiroshi Oshio
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-Ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, 2-2-2 Iidanishi, Yamagata Prefecture, Yamagata, 990-9585, Japan
| | - Yukiko Oshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-Ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Gen Yunome
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-Ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Shinji Okazaki
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
| | - Ichiro Kawamura
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
| | - Yuya Ashitomi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
| | - Masaaki Kawai
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
| | - Hiroaki Musha
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan
| | - Fuyuhiko Motoi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 IidanishiYamagata Prefecture, Yamagata, 990-9585, Japan.
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Bayat Z, Guidolin K, Elsolh B, De Castro C, Kennedy E, Govindarajan A. Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review. BJS Open 2022; 6:6704875. [PMID: 36124901 PMCID: PMC9487584 DOI: 10.1093/bjsopen/zrac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS. Methods A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration. Results A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS. Conclusion Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.
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Affiliation(s)
- Zubair Bayat
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Keegan Guidolin
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | - Basheer Elsolh
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
| | | | - Erin Kennedy
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
| | - Anand Govindarajan
- Division of General Surgery, Department of Surgery, University of Toronto , Toronto, Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto , Toronto, Ontario , Canada
- Sinai Health System , Toronto, Ontario , Canada
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Mizrahi I, Abu-Gazala M, Fernandez LM, Krizzuk D, Ioannidis A, Wexner SD. Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease. Colorectal Dis 2021; 23:2948-2954. [PMID: 34310016 DOI: 10.1111/codi.15837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
AIM The aim of this work was to compare the results of elective minimally invasive surgery between patients with complicated sigmoid diverticulitis and those with uncomplicated disease. METHOD An institutional review board-approved database was searched for all consecutive patients who underwent elective minimally invasive surgery, including laparoscopic, hand-assisted and robotic sigmoidectomy, for diverticulitis between 2010 and 2017; they were classified according to the modified Hinchey classification as having complicated (abscess, fistula, stricture, obstruction, bleeding or previous perforation) versus uncomplicated disease. Data recorded included baseline demographics, indications for surgery, operative details and complications. RESULTS Three hundred and twenty-five patients underwent elective sigmoidectomy for complicated (n = 105) and uncomplicated (n = 220) diverticulitis. Surgical indications for complicated disease were abscess (n = 74), stricture (n = 14), fistula (n = 28) and bleeding (n = 7). The two groups were statistically comparable for age, gender, body mass index and American Society of Anesthesiologists score. Patients with complicated disease had higher rates of concomitant loop ileostomy creation (9.5% vs. 0.9%, p < 0.001) and synchronous resections (9.5% vs. 2.7%, p = 0.01), higher volumes of blood loss (177 ± 140 vs. 125 ± 92 ml, p < 0.001), longer length of stay (5.6 ± 3 vs. 4.8 ± 2 days, p = 0.04) and longer operating time (218.2 ± 59 vs. 185.8 ± 63 min, p < 0.001). There were no significant differences in anastomotic leakage (3% vs. 1%, p = 0.3), conversion to laparotomy (4.8% vs. 2.3%, p = 0.3) or overall complications (36% vs. 25.9%, p = 0.06) for complicated versus uncomplicated disease, respectively. CONCLUSION Minimally invasive surgery for complicated diverticulitis resulted in higher rates of construction of proximal ileostomy and synchronous resections and longer operating times and length of hospital stay. Otherwise, it has outcomes that are not significantly different from the results recorded in patients with uncomplicated disease.
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Affiliation(s)
- Ido Mizrahi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mahmoud Abu-Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Laura M Fernandez
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Argyrios Ioannidis
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Katayama H, Inomata M, Mizusawa J, Nakamura K, Watanabe M, Akagi T, Yamamoto S, Ito M, Kinugasa Y, Okajima M, Takemasa I, Okuda J, Shida D, Kanemitsu Y, Kitano S. Institutional variation in survival and morbidity in laparoscopic surgery for colon cancer: From the data of a randomized controlled trial comparing open and laparoscopic surgery (JCOG0404). Ann Gastroenterol Surg 2021; 5:823-831. [PMID: 34755014 PMCID: PMC8560602 DOI: 10.1002/ags3.12484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/14/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Institutional variation in outcomes is a key factor to ascertain the generalizability of results and reliability of the clinical trial. This study evaluated institutional variation in survival and postoperative complications using data from JCOG0404 comparing laparoscopic colectomy (LAP) with open colectomy (OP). METHODS Institutions with fewer than 10 registered patients were excluded from this analysis. Institutional variation was evaluated in terms of early postoperative complications, overall survival, and relapse-free survival and estimated using a mixed-effect model with institution as a random effect after adjusting for background factors. RESULTS This analysis included 1028 patients in the safety analysis and 1040 patients in the efficacy analysis from 26 institutions. In the safety analysis, there was no variation in grades 3-4 early postoperative complications (in OP, median 6.3% [range 6.3%-6.3%]; in LAP, median 2.6% [range 2.6%-2.6%]), but some variation in grades 1-4 early postoperative complications was observed (in OP, median 20.8% [range 13.2%-31.8%]; in LAP, median 11.9% [range 7.2%-28.7%]), and that in grades 2-4 was observed only in LAP (median 8.8% [range 4.7%-24.0%]; in OP, median 12.7% [range 12.7%-12.7%]). Two specific institutions showed especially high incidences of postoperative complications in LAP. In the efficacy analysis, there was no institutional variation in OP, although a certain variation was observed in LAP. CONCLUSIONS Some institutional variations in safety and efficacy were observed, although only in LAP. We conclude that a qualification system, including training and education, is needed when new surgical techniques such as laparoscopic surgery are introduced in clinical practice.
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Affiliation(s)
- Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | - Kenichi Nakamura
- Japan Clinical Oncology Group Data Center/Operations OfficeNational Cancer Center HospitalTokyoJapan
| | - Masahiko Watanabe
- Department of SurgeryKitasato University Kitasato Institute HospitalTokyoJapan
| | - Tomonori Akagi
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Seiichiro Yamamoto
- Department of Gastroenterological SurgeryTokai University School of MedicineKanagawaJapan
| | - Masaaki Ito
- Department of Colorectal SurgeryNational Cancer Center Hospital EastChibaJapan
| | - Yusuke Kinugasa
- Department of Gastrointestinal SurgeryTokyo Medical and Dental UniversityTokyoJapan
| | - Masazumi Okajima
- Department of SurgeryHiroshima City Hiroshima Citizens HospitalHiroshimaJapan
| | - Ichiro Takemasa
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversityHokkaidoJapan
| | - Junji Okuda
- General and Gastroenterological SurgeryOsaka Medical CollegeOsakaJapan
| | - Dai Shida
- Department of Colorectal SurgeryNational Cancer Center HospitalTokyoJapan
| | - Yukihide Kanemitsu
- Department of Colorectal SurgeryNational Cancer Center HospitalTokyoJapan
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Matsuzaki S, Klar M, Chang EJ, Matsuzaki S, Maeda M, Zhang RH, Roman LD, Matsuo K. Minimally Invasive Surgery and Surgical Volume-Specific Survival and Perioperative Outcome: Unmet Need for Evidence in Gynecologic Malignancy. J Clin Med 2021; 10:jcm10204787. [PMID: 34682910 PMCID: PMC8537091 DOI: 10.3390/jcm10204787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023] Open
Abstract
This study examined the effect of hospital surgical volume on oncologic outcomes in minimally invasive surgery (MIS) for gynecologic malignancies. The objectives were to assess survival outcomes related to hospital surgical volume and to evaluate perioperative outcomes and examine non-gynecologic malignancies. Literature available from the PubMed, Scopus, and the Cochrane Library databases were systematically reviewed. All surgical procedures including gynecologic surgery with hospital surgical volume information were eligible for analysis. Twenty-three studies met the inclusion criteria, and nine gastro-intestinal studies, seven genitourinary studies, four gynecological studies, two hepatobiliary studies, and one thoracic study were reviewed. Of those, 11 showed a positive volume–outcome association for perioperative outcomes. A study on MIS for ovarian cancer reported lower surgical morbidity in high-volume centers. Two studies were on endometrial cancer, of which one showed lower treatment costs in high-volume centers and the other showed no association with perioperative morbidity. Another study examined robotic-assisted radical hysterectomy for cervical cancer and found no volume–outcome association for surgical morbidity. There were no gynecologic studies examining the association between hospital surgical volume and oncologic outcomes in MIS. The volume–outcome association for oncologic outcome in gynecologic MIS is understudied. This lack of evidence calls for further studies to address this knowledge gap.
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Affiliation(s)
- Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Correspondence: ; Tel.: +81-6-6879-3355; Fax: +81-6-6879-3359
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, 79085 Freiburg, Germany;
| | - Erica J. Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
| | - Satoko Matsuzaki
- Department of Obstetrics and Gynecology, Osaka General Medical Center, Osaka 558-8558, Japan;
| | - Michihide Maeda
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Renee H. Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA;
| | - Lynda D. Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
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Bader NA, Sweeney M, Zeymo A, Villano AM, Houlihan B, Bayasi M, Al-Refaie WB, Chan KS. Defining a minimum hospital volume threshold for minimally invasive colon cancer resections. Surgery 2021; 171:293-298. [PMID: 34429201 DOI: 10.1016/j.surg.2021.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic colectomy is considered the standard of care in colon cancer treatment when appropriate expertise is available. However, guidelines do not delineate what experience is required to implement this approach safely and effectively. This study aimed to establish a data-derived, hospital-level annual volume threshold for laparoscopic colectomy at which patient outcomes are optimized. METHODS This evaluation included 44,157 stage I to III adenocarcinoma patients aged ≥40 years who underwent laparoscopic colon resection between 2010 and 2015 within the National Cancer Database. The primary outcome was overall survival, with 30- and 90-day mortality, duration of stay, days to receipt of chemotherapy, and number of lymph nodes examined as secondary. Segmented logistic and Cox regression models were used to identify volume thresholds which optimized these outcomes. RESULTS In hospitals performing ≥30 laparoscopic colectomies per year there were incremental improvements in overall survival for each additional resection beyond 30. Hospitals performing ≥30 procedures/year demonstrated improved 30-day mortality (1.3% vs 1.7%, P < .001), 90-day mortality (2.3% vs 2.9%, P < .001), and overall survival (84.3% vs 82.3%, P < .001). Those hospitals performing <30 procedures/year had no significant benefit in overall survival. Thresholds were not identified for any other outcomes. Results were comparable in colon cancer patients with stage IV or multiple cancers. CONCLUSION A high-volume hospital threshold of ≥30 cases/year for laparoscopic colectomies is associated with improved patient survival and outcomes. A minimum volume standard may help providers determine which approach is most suitable for their hospital's practice as open procedures may yield better oncologic results in low volume settings.
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Affiliation(s)
- Nicholas A Bader
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Matthew Sweeney
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | - Anthony M Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Brenna Houlihan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Mohammed Bayasi
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; Department of Colorectal Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; Department of Surgical Oncology, MedStar-Georgetown University Hospital, Washington, DC.
| | - Kitty S Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
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Franchini Melani AG, Capochin Romagnolo LG. Management of postoperative complications during laparoscopic anterior rectal resection. Minerva Surg 2021; 76:324-331. [PMID: 33944518 DOI: 10.23736/s2724-5691.21.08890-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.
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Affiliation(s)
- Armando G Franchini Melani
- Americas Medical City, Rio de Janeiro, Brazil - .,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil -
| | - Luis G Capochin Romagnolo
- Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil.,Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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Kastner C, Reibetanz J, Germer CT, Wiegering A. [Evidence in minimally invasive oncological surgery of the colon and rectum]. Chirurg 2021; 92:334-343. [PMID: 33263772 DOI: 10.1007/s00104-020-01320-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An essential component of the treatment of colorectal cancer is a resection of the tumor-bearing segment of the bowels. After the development of minimally invasive procedures the feasibility and safety in oncological, colorectal surgery was questioned. The broad study situation for colon cancer over the last years showed predominantly consistent benefits during the perioperative phase and non-inferiority concerning long-term oncological outcomes. The implementation of laparoscopic rectal resection was more hesitant due to the complexity of the procedure and insufficient study data; however, overall the short-term benefits seem to be maintained and laparoscopic rectal resection is thought to be noninferior to open resection in the long run even though findings on the quality of the resected specimen are heterogeneous. Accordingly, most guidelines now include a recommendation of laparoscopic resection for colorectal cancer. The limitation with respect to an achievable oncological equivalency of resection takes account of the complexity and the requirements of the intervention only in the setting of rational selection of patients and sufficient experience of the surgeon.
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Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie I, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie I, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
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10
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Allaix ME, Rebecchi F, Fichera A. The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery. Ann Surg Oncol 2020; 27:3704-3715. [PMID: 32648183 DOI: 10.1245/s10434-020-08833-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/19/2020] [Indexed: 12/31/2022]
Abstract
Current high-quality evidence supports the routine use of the laparoscopic approach for patients with colon cancer. Laparoscopic colectomy is associated with earlier resumption of gastrointestinal function and shorter hospital stay, with no increased morbidity or mortality. Pathology and long-term oncologic outcomes are similar to those achieved with open surgery. The absolute benefits of laparoscopic resection for rectal cancer are still under evaluation. While its safety in terms of early postoperative clinical outcomes has been confirmed, two recent randomized controlled trial (RCTs) have questioned its routine use even in expert hands, since its non-inferiority has not been demonstrated when compared with the gold standard of open surgery. Furthermore, the impact of robotic technology is still unclear, since the only RCT available so far failed to demonstrate any benefits compared with standard laparoscopic rectal resection.
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Affiliation(s)
- Marco E Allaix
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | | | - Alessandro Fichera
- Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, 3409 Worth Street. Worth Tower, Suite 640, Dallas, TX, 75246, USA.
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11
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MacCallum C, Da Silva N, Skandarajah A, Hayes I. Study of colorectal cancer resection patterns across the state of Victoria using validated administrative data algorithms. ANZ J Surg 2020; 90:308-313. [PMID: 32039566 DOI: 10.1111/ans.15710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Administrative data provide a unique opportunity to examine whole-of-state colorectal cancer (CRC) data. The purpose of this study was to compare types of CRC resection across Victorian geographical zones, using hospital volume and accredited training-post status. METHODS All CRC resections in Victorian public hospitals between 2008 and 2013 were analysed using validated algorithms of administrative data from the Victorian Admitted Episodes Dataset. Hospitals were grouped according to Colorectal Surgical Society of Australia and New Zealand (CSSANZ) training-post status, case-volume (high >200 in 5 years) and remoteness of location. Resection frequency and type were compared. RESULTS In 44 public hospitals over 6 years, 7596 CRC resections were performed. Patient age, American Society of Anesthesiologists Physical Status Classification System score and tumour stage were similar among groups. CSSANZ accounted for nearly 50% of cases but the lowest percentage of emergencies (16.8%). The ratio of right-sided to left-sided plus rectal resections was greater for low-volume than high-volume centres (56.8% versus 40.4%), while left colon and rectal resections comprised a larger proportion of high-volume workload. High- compared with low-volume favoured ultra-low anterior resections (62% versus 33%) over abdominoperineal resections (38% versus 67%). Work patterns among high-volume hospitals were similar regardless of remoteness or CSSANZ status. CONCLUSION This study demonstrated that administrative data can provide granular, clinically relevant information with population-wide coverage. Most public CRC resections in Victoria were performed in metropolitan hospitals. The majority of rectal cancer resections were performed in high-volume metropolitan centres but 15% were performed by low-volume regional hospitals.
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Affiliation(s)
- Caroline MacCallum
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Da Silva
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anita Skandarajah
- Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian Hayes
- Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of General Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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12
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Abstract
Colon cancer is the second leading cause of cancer death in the United States. Advances in surgical resection techniques, including minimally invasive colectomy, are becoming a standard of care. The oncologic principles of colectomy have included adequate lymphadenectomy, proximal ligation of primary vessels, and resection with adequate longitudinal margins. More recently, complete mesocolic excision has been advocated. Open and minimally invasive approaches must accomplish the same outcomes. This article focuses on the surgical principles of colon cancer, perioperative considerations, and technical aspects of minimally invasive colectomy. We review the current literature regarding oncologic and short-term outcomes of minimally invasive surgery.
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Affiliation(s)
- Katerina O Wells
- Department of Surgery, Baylor University Medical Center, 3409 Worth Street, Suite 640, Dallas, TX 75246, USA.
| | - Anthony Senagore
- Department of Surgery, Western Michigan University, Homer Stryker School of Medicine, 1903 Western Michigan Avenue, Kalamazoo, MI 49008, USA
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13
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Pediatric Training and Experience Requirements—Development of UNOS Bylaws. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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14
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Furnes B, Storli KE, Forsmo HM, Karliczek A, Eide GE, Pfeffer F. Risk Factors for Complications following Introduction of Radical Surgery for Colon Cancer: A Consecutive Patient Series. Scand J Surg 2018; 108:144-151. [PMID: 30187819 DOI: 10.1177/1457496918798208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Rectal cancer surgery is standardized, resulting in improved survival. Colon cancer has fallen behind and therefore more radical surgical techniques have been introduced. One technique is complete mesocolic excision. The aim of this article was to study the complications after the introduction of standardized complete mesocolic excision in a single center. METHODS Complete mesocolic excision was introduced in 2007, and data were collected from 286 patients prior to surgery (2007-2010). The surgeon decided on open or laparoscopic surgery. Follow-up information was recorded until 31 December 2015. Complications were classified according to a modified Clavien-Dindo classification. RESULTS Complications occurred in 47%, severe complications (grade III and IV) in 15%. In-hospital mortality was 3.5%. A total of 142 patients (49.7%) were operated by open surgery. Logistic regression revealed anemia (p = 0.001), open surgery (p < 0.001), and long operating time (p < 0.001) as significant factors for complications in general. Multinomial logistic regression revealed that severe complications occurred more often in males (odds ratio: 2.56; 95% confidence interval: 0.98-6.68), patients with anemia (odds ratio: 3.49; 95% confidence interval: 1.27-9.60), elevated body mass index (odds ratio: 1.14; 95% confidence interval: 1.02-1.28), and in open surgery (odds ratio: 9.95; 95% confidence interval: 2.58-38.35). Age was not associated with severe complications. Survival was not significantly influenced by complications. Overall survival (5 years) was 90% among patients with complications and 92% among those without complications. CONCLUSION Severe complications following the introduction of complete mesocolic excision are patient dependent and related to open surgery. Patients selected for laparoscopy had less number of complications; therefore, introducing complete mesocolic excision by laparoscopy is justified. Identification of these factors can improve selection of appropriate surgical approach and postoperative patient safety.
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Affiliation(s)
- B Furnes
- 1 Department of Gastrointestinal and Emergency Surgery, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - K E Storli
- 2 Department of Clinical Science, University of Bergen, Bergen, Norway.,3 Department of Gastrointestinal Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - H M Forsmo
- 1 Department of Gastrointestinal and Emergency Surgery, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - A Karliczek
- 1 Department of Gastrointestinal and Emergency Surgery, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, University of Bergen, Bergen, Norway
| | - G E Eide
- 4 Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,5 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - F Pfeffer
- 1 Department of Gastrointestinal and Emergency Surgery, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, University of Bergen, Bergen, Norway
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15
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Felder SI, Ramanathan R, Russo AE, Jimenez-Rodriguez RM, Hogg ME, Zureikat AH, Strong VE, Zeh HJ, Weiser MR. Robotic gastrointestinal surgery. Curr Probl Surg 2018; 55:198-246. [PMID: 30470267 PMCID: PMC6377083 DOI: 10.1067/j.cpsurg.2018.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Seth I Felder
- Department of Gastrointestinal Surgery, Moffitt Cancer Center, Tampa, Florida
| | - Rajesh Ramanathan
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ashley E Russo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Herbert J Zeh
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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16
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Jimenez-Rodriguez RM, Weiser MR. In Brief. Curr Probl Surg 2018; 55:194-195. [PMID: 30470266 DOI: 10.1067/j.cpsurg.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2025]
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17
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Ackerman SJ, Daniel S, Baik R, Liu E, Mehendale S, Tackett S, Hellan M. Comparison of complication and conversion rates between robotic-assisted and laparoscopic rectal resection for rectal cancer: which patients and providers could benefit most from robotic-assisted surgery? J Med Econ 2018; 21:254-261. [PMID: 29065737 DOI: 10.1080/13696998.2017.1396994] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS To compare (1) complication and (2) conversion rates to open surgery (OS) from laparoscopic surgery (LS) and robotic-assisted surgery (RA) for rectal cancer patients who underwent rectal resection. (3) To identify patient, physician, and hospital predictors of conversion. MATERIALS AND METHODS A US-based database study was conducted utilizing the 2012-2014 Premier Healthcare Data, including rectal cancer patients ≥18 with rectal resection. ICD-9-CM diagnosis and procedural codes were utilized to identify surgical approaches, conversions to OS, and surgical complications. Propensity score matching on patient, surgeon, and hospital level characteristics was used to create comparable groups of RA\LS patients (n = 533 per group). Predictors of conversion from LS and RA to OS were identified with stepwise logistic regression in the unmatched sample. RESULTS Post-match results suggested comparable perioperative complication rates (RA 29% vs LS 29%; p = .7784); whereas conversion rates to OS were 12% for RA vs 29% for LS (p < .0001). Colorectal surgeons (RA 9% vs LS 23%), general surgeons (RA 13% vs LS 35%), and smaller bed-size hospitals (RA 14% vs LS 33%) have reduced conversion rates for RA vs LS (p < .0001). Statistically significant predictors of conversion included LS, non-colorectal surgeon, and smaller bed-size hospitals. LIMITATIONS Retrospective observational study limitations apply. Analysis of the hospital administrative database was subject to the data captured in the database and the accuracy of coding. Propensity score matching limitations apply. RA and LS groups were balanced with respect to measured patient, surgeon, and hospital characteristics. CONCLUSIONS Compared to LS, RA offers a higher probability of completing a successful minimally invasive surgery for rectal cancer patients undergoing rectal resection without exacerbating complications. Male, obese, or moderately-to-severely ill patients had higher conversion rates. While colorectal surgeons had lower conversion rates from RA than LS, the reduction was magnified for general surgeons and smaller bed-size hospitals.
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Affiliation(s)
| | | | - Rebecca Baik
- b Covance Market Access Services , Gaithersburg , MD , USA
| | - Emelline Liu
- c Health Economics and Outcomes Research, Intuitive Surgical , Sunnyvale , CA , USA
| | | | - Scott Tackett
- c Health Economics and Outcomes Research, Intuitive Surgical , Sunnyvale , CA , USA
| | - Minia Hellan
- e Surgical Oncology, Wright State University , Centerville , OH , USA
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18
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Laparoscopic conversion in colorectal cancer surgery; is there any improvement over time at a population level? Surg Endosc 2018; 32:3234-3246. [PMID: 29344789 PMCID: PMC5988765 DOI: 10.1007/s00464-018-6042-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/03/2018] [Indexed: 12/16/2022]
Abstract
Conversion of laparoscopic colorectal cancer resection has been associated with worse outcome, but this might have been related to a learning curve effect. This study aimed to evaluate incidence, predictive factors and outcomes of laparoscopic conversion after the implementation phase of laparoscopic surgery at a population level. Patients undergoing elective resection of non-locally advanced, non-metastatic colorectal cancer between 2011 and 2015 were included. Data were extracted from the Dutch Surgical Colorectal Audit. Patients were grouped as laparoscopic completed (LR), laparoscopic converted (CONV) with further specification of timing (within or after 30 min) as registered in the DSCA, and open resection (OR). Uni- and multi-variate analyses were used to determine predictors of conversion and outcome (complicated course and mortality), with evaluation of trends over time. A total of 23,044 patients with colon cancer and 11,324 with rectal cancer were included. Between 2011 and 2015, use of laparoscopy increased from 55 to 84% in colon cancer, and from 49 to 89% in rectal cancer. Conversion rates decreased from 11.8 to 8.6% and from 13 to 8.0%, respectively. Laparoscopic hospital volume was independently associated with conversion rate. Only for colon cancer, the rate of complicated course was significantly higher after CONV compared to OR (adjusted odds ratio 1.486; 95% CI 1.298-1.702), and significantly higher after late (> 30 min) compared to early conversion (adjusted odds ratio 1.341; 1.046-1.719). There was no impact of CONV on mortality in both colon and rectal cancer. The use of laparoscopic colorectal cancer surgery increased to more than 80% at a national level, accompanied by a decrease in conversion which is significantly related to the laparoscopic hospital volume. Conversion was only associated with complicated course in colon cancer, especially when the reason for conversion consisted of an intra-operative complication, without affecting mortality.
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19
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Long-term outcomes of sigmoid diverticulitis: a single-center experience. J Surg Res 2017; 221:8-14. [PMID: 29229157 DOI: 10.1016/j.jss.2017.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/25/2017] [Accepted: 07/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND During the last decade, guidelines for the treatment of sigmoid diverticulitis have dramatically changed. The aim of this study is to report the long-term outcomes of patients treated for diverticulitis at a nonspecialized single center. MATERIALS AND METHODS After obtaining institutional review board approval, medical records of all patients admitted to our institution with the diagnosis of sigmoid diverticulitis between 1998 and 2008 were reviewed. A follow-up of at least 5 years was required. RESULTS During the study period, 266 patients were admitted to our hospital due to sigmoid diverticulitis with a mean follow-up period of 120 ± 2 months. Of the entire cohort, 249 patients (93.5%) were treated conservatively and 17 (6.5%) patients required emergent surgery on initial presentation. Patients treated conservatively (n = 249) encountered a median of two recurrent episodes (range 0-4). During follow-up, none of these patients required emergent surgery, and 27 patients (11%) underwent elective surgery for recurrent episodes (n = 24), chronic smoldering disease (n = 2), and fistula (n = 1). Minor and major complication rates after elective surgery were 18.5% and 30%, respectively. Specifically, four patients (15%) suffered an anastomotic leak (AL). Late complications after elective surgery occurred in 33% of patients including incisional hernias (11%), bowel obstruction (3.7%), anastomotic stenosis (3.7%), and recurrent diverticulitis (15%). CONCLUSIONS Patients treated conservatively during their index admission for sigmoid diverticulitis do not require emergent surgery during long-term follow-up and the majority of patients (89%) do not require elective surgery. Elective sigmoidectomy at nonspecialized centers may result in high rates of recurrent diverticulitis (15%) and anastomotic leak (15%).
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20
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Pajarón-Guerrero M, Fernández-Miera MF, Dueñas-Puebla JC, Cagigas-Fernández C, Allende-Mancisidor I, Cristóbal-Poch L, Gómez-Fleitas M, Manzano-Peral MA, Gonzalez-Fernandez CR, Aguilera-Zubizarreta A, Sanroma-Mendizábal P. Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery. Eur Surg Res 2017; 58:263-273. [PMID: 28793287 DOI: 10.1159/000479004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 06/26/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. METHODS A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. RESULTS A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. CONCLUSIONS For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.
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Affiliation(s)
- Marcos Pajarón-Guerrero
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Carmen Cagigas-Fernández
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Lidia Cristóbal-Poch
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Gómez-Fleitas
- Department of General and Gastrointestinal Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Ana Aguilera-Zubizarreta
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Pedro Sanroma-Mendizábal
- Domiciliary Hospitalisation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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21
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Huo YR, Phan K, Morris DL, Liauw W. Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. J Gastrointest Oncol 2017; 8:534-546. [PMID: 28736640 DOI: 10.21037/jgo.2017.01.25] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Numerous hospitals worldwide are considering setting minimum volume standards for colorectal surgery. This study aims to examine the association between hospital and surgeon volume on outcomes for colorectal surgery. METHODS Two investigators independently reviewed six databases from inception to May 2016 for articles that reported outcomes according to hospital and/or surgeon volume. Eligible studies included those in which assessed the association hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. Random effects models were used to pool the hazard ratios (HRs) for the association between hospital/surgeon volume with outcomes. RESULTS There were 47 articles pooled (1,122,303 patients, 9,877 hospitals and 9,649 surgeons). The meta-analysis demonstrated that there is a volume-outcome relationship that favours high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality (HR: 0.83; 95% CI: 0.78-0.87, P<0.001 & HR: 0.84; 95% CI: 0.80-0.89, P<0.001 respectively) and intra-operative mortality (HR: 0.82; 95% CI: 0.76-0.86, P<0.001 & HR: 0.50; 95% CI: 0.40-0.62, P<0.001 respectively). Post-operative complication rates depended on hospital volume (HR: 0.89; 95% CI: 0.81-0.98, P<0.05), but not surgeon volume except with respect to anastomotic leak (HR: 0.59; 95% CI: 0.37-0.94, P<0.01). High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, whilst reducing recurrence rates, operative time, length of stay and cost. The best outcomes occur in high volume hospitals with high volume surgeons, followed by low volume hospitals with high volume surgeons. CONCLUSIONS High volume by surgeon and high volume by hospital are associated with better outcomes for colorectal cancer surgery. However, this relationship is non-linear with no clear threshold of effect being identified and an apparent ceiling of effect.
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Affiliation(s)
- Ya Ruth Huo
- Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David L Morris
- Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia
| | - Winston Liauw
- Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
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22
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23
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van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
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Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
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24
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Patient factors predisposing to complications following laparoscopic surgery for colorectal cancers. Surg Laparosc Endosc Percutan Tech 2016; 25:168-72. [PMID: 25383941 DOI: 10.1097/sle.0000000000000110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to clarify patient factors contributing to complications after laparoscopic surgery for colorectal cancers. A total of 333 colorectal cancer patients who underwent laparoscopic colorectal resection between January 2007 and December 2012 were enrolled. The association between patient factors and the incidence of complications were analyzed. Postoperative complications were divided into 2 categories: infectious complications and noninfectious complications. The overall complication rate was 13% and mortality rate 0%. Multivariate analysis showed that body mass index >25 kg/m [odds ratio (OR)=3.02, P=0.0254] and tumor location (right colon cancer/rectal cancer: OR=0.11, P=0.0083) were risk factors for infectious complications; in addition, male sex (OR=3.91, P=0.0102) and cancer stage (stage 2/stage 4: OR=0.17, P=0.0247) were risk factors for noninfectious complications. This study shows that different patient factors are associated with the risk of different types of complications.
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Increased Caseload Volume is Associated With Better Oncologic Outcomes After Laparoscopic Resections for Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:49-53. [DOI: 10.1097/sle.0000000000000221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Colorectal surgery in a rural setting. Updates Surg 2015; 67:407-19. [DOI: 10.1007/s13304-015-0331-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/21/2015] [Indexed: 01/27/2023]
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Risk factors for conversion of laparoscopic colorectal surgery to open surgery: does conversion worsen outcome? World J Surg 2015; 39:1240-7. [PMID: 25631940 DOI: 10.1007/s00268-015-2958-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The utilization of laparoscopy in colorectal surgery is increasing. However, conversion to open surgery remains relatively high. OBJECTIVE We evaluated (1) conversion rates in laparoscopic colorectal surgery; (2) the outcomes of converted cases compared with successful laparoscopic and open colorectal operations; (3) predictive risk factors of conversion of laparoscopic colorectal surgery to open surgery. METHODS Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. Multivariate regression analysis was performed to identify factors predictive for conversion of laparoscopic to open operation. RESULTS A total of 207,311 patients underwent intended laparoscopic colorectal resection during this period. The conversion rate was 16.6 %. Considering resection type and pathology, the highest conversion rates were observed in proctectomy (31.4 %) and Crohn's disease (20.2 %). Using multivariate regression analysis, Crohn's disease (adjusted odds ratio [AOR], 2.80), prior abdominal surgery (AOR, 2.45), proctectomy (AOR, 2.42), malignant pathology (AOR, 1.90), emergent surgery (AOR, 1.82), obesity (AOR, 1.63), and ulcerative colitis (AOR, 1.60) significantly impacted the risk of conversion. Compared with patients who were successfully completed laparoscopically, converted patients had a significantly higher complication rate (laparoscopic: 23 %; vs. converted: 35.2 % vs. open: 35.3 %), a higher in-hospital mortality rate (laparoscopic: 0.5 %; vs. converted: 0.6 %; vs. open: 1.7 %) and a longer mean hospital stay (laparoscopic: 5.4 days; vs. converted: 8.1 days; vs. open: 8.4 days); however, converted patients had better outcomes compared with the open group. CONCLUSIONS The conversion rate in colorectal surgery was 16.6 %. Converted patients had significantly higher rates of morbidity and mortality compared to successfully completed laparoscopic cases, although lower than open cases. Crohn's disease, prior abdominal surgery, and proctectomy are the strongest predictors for conversion of laparoscopic to open in colorectal operations.
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Elnahas A, Sunil S, Jackson TD, Okrainec A, Quereshy FA. Laparoscopic versus open surgery for T4 colon cancer: evaluation of margin status. Surg Endosc 2015; 30:1491-6. [PMID: 26123344 DOI: 10.1007/s00464-015-4360-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 06/18/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic resection has been considered a relative contraindication for T4 colonic and rectal lesions due to concern over inadequate margins. The objective of this study was to compare planned laparoscopic and open resections of T4 lesions with respect to the positive margin rate. METHODS Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients that underwent a colorectal resection for a primary T4 lesion during 2011 and 2012. A multiple logistic regression analysis was conducted to determine the adjusted odds ratio (OR) of positive margins based on surgical approach. An inverse probability of treatment weighting (IPTW) analysis was used to account for confounding by indication. A sensitivity analysis including only "as-treated" cases was also performed. RESULTS The sub-selected population consisted of 455 and 406 patients in the laparoscopic and open group, respectively. In the original cohort, demographic variables were similar. The open group had a higher incidence of comorbidities, metastatic disease, and emergency cases. Laparoscopic surgery was found to be no different than open surgery with respect to positive margin status (OR 1.10, p = 0.54). After IPTW adjustment, surgical approach remained a nonsignificant predictor of positive margins (OR 1.18, p = 0.31). The "as-treated" analysis also showed that surgical approach had no significant effect on the positive margin rate (OR 1.24, p = 0.24). CONCLUSIONS Using this large national surgical database, select patients with T4 lesions who underwent planned laparoscopic colorectal resections did not have a significantly higher positive margin rate compared with patients with open operations. Further research is needed to identify the role of laparoscopy in managing T4b lesions before any consensus can be reached regarding its application in locally advanced colon cancer.
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Affiliation(s)
- Ahmad Elnahas
- Department of Surgery, Toronto Western Hospital - University Health Network, University of Toronto, 399 Bathurst Street, Room 8MP - 320, Toronto, ON, M5T 2S8, Canada
| | - Supreet Sunil
- Department of Surgery, Toronto Western Hospital - University Health Network, University of Toronto, 399 Bathurst Street, Room 8MP - 320, Toronto, ON, M5T 2S8, Canada
| | - Timothy D Jackson
- Department of Surgery, Toronto Western Hospital - University Health Network, University of Toronto, 399 Bathurst Street, Room 8MP - 320, Toronto, ON, M5T 2S8, Canada
| | - Allan Okrainec
- Department of Surgery, Toronto Western Hospital - University Health Network, University of Toronto, 399 Bathurst Street, Room 8MP - 320, Toronto, ON, M5T 2S8, Canada
| | - Fayez A Quereshy
- Department of Surgery, Toronto Western Hospital - University Health Network, University of Toronto, 399 Bathurst Street, Room 8MP - 320, Toronto, ON, M5T 2S8, Canada. .,Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
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Vargas-Palacios A, Hulme C, Veale T, Downey CL. Systematic Review of Retraction Devices for Laparoscopic Surgery. Surg Innov 2015; 23:90-101. [DOI: 10.1177/1553350615587991] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background. Retraction plays a vital role in optimizing the field of vision in minimal-access surgery. As such, a number of devices have been marketed to aid the surgeon in laparoscopic retraction. This systematic review explores the advantages and disadvantages of the different instruments in order to aid surgeons and their institutions in selecting the appropriate device. Primary outcome measures include operation time, length of stay, use of staff, patient morbidity, ease of use, conversion rates to open surgery, and cost. Methods. Systematic literature searches were performed in MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials, and ClinicalTrials.gov. The search strategy focused on studies testing a retraction device. The selection process was based on a predefined set of inclusion and exclusion criteria. Data were then extracted and analyzed. Results. Out of 1360 papers initially retrieved, 12 articles were selected for data extraction and analysis. A total of 10 instruments or techniques were tested. Devices included the Nathanson’s liver retractor, liver suspension tape, the V-List technique, a silicone disk with or without a snake retractor, the Endoloop, the Endograb, a magnetic retractor, the VaroLift, a laparoscope holder, and a retraction sponge. None of the instruments reported were associated with increased morbidity. No studies found increased rates of conversion to open surgery. All articles reported that the tested instruments might spare the use of an assistant during the procedure. It was not possible to determine the impact on length of stay or operation time. Conclusions. Each analyzed device facilitates retraction, providing a good field of view while allowing reduced staff numbers and minimal patient morbidity. Due to economic and environmental advantages, reusable devices may be preferable to disposable instruments, although the choice must be primarily based on clinical judgement.
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Mackenzie H, Ni M, Miskovic D, Motson RW, Gudgeon M, Khan Z, Longman R, Coleman MG, Hanna GB. Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery. Br J Surg 2015; 102:991-7. [DOI: 10.1002/bjs.9828] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes.
Methods
Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis.
Results
Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P < 0·001).
Conclusion
An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.
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Affiliation(s)
- H Mackenzie
- Department of Surgery and Cancer, Imperial College, London, UK
| | - M Ni
- Department of Surgery and Cancer, Imperial College, London, UK
| | - D Miskovic
- John Goligher Colorectal Unit, Leeds Teaching Hospitals, Leeds, UK
| | - R W Motson
- ICENI Centre, Colchester Hospital, Colchester, UK
| | - M Gudgeon
- Colorectal Unit, Frimley Park Hospital, Frimley, UK
| | - Z Khan
- Colorectal Unit, Queen Elizabeth Hospital, King's Lynn, UK
| | - R Longman
- Colorectal Unit, Bristol Royal Infirmary, Bristol, UK
| | - M G Coleman
- Colorectal Unit, Derriford Hospital, Plymouth, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College, London, UK
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Methods of quality assurance in multicenter trials in laparoscopic colorectal surgery: a systematic review. Ann Surg 2015; 260:220-9. [PMID: 24743623 DOI: 10.1097/sla.0000000000000660] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess the risk of bias in multicenter randomized controlled trials (RCTs) investigating laparoscopic colorectal cancer surgery and review the use of quality assurance mechanisms to reduce performance bias. BACKGROUND RCTs represent the criterion standard comparison for health care interventions. For trials investigating interventional techniques, performance bias can arise through variation in delivery of the intervention. METHODS A comprehensive systematic review was undertaken using MEDLINE and EMBASE databases to identify all large RCTs investigating laparoscopic colorectal cancer surgery. Risk of performance bias was evaluated through assessment of publications and protocols to identify methods used for quality assurance of surgical technique. In addition, the Cochrane Collaboration's "risk of bias" tool was used to evaluate other potential sources of bias. RESULTS The literature search identified 48 publications, reporting upon 8 individual RCTs. All studies used mechanisms for quality assurance of laparoscopic colorectal surgery. Methods employed included credentialing of surgeons or units through assessment of experience and expertise, standardization of surgical technique, and monitoring. None report the use of structure objective assessment tools for accrediting expertise. All 8 were assessed as low risk of bias using the Cochrane tool. A framework is proposed for use as a model for quality assurance in future surgical trials. CONCLUSIONS Consideration of risk of performance bias is important when appraising trials investigating an interventional technique. Laparoscopic colorectal surgery RCTs have all employed quality assurance mechanisms to reduce risk of performance bias. Further research is indicated to investigate adopting objective assessment tools for quality assurance within multicenter RCTs.
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Zheng Z, Jemal A, Lin CC, Hu CY, Chang GJ. Comparative effectiveness of laparoscopy vs open colectomy among nonmetastatic colon cancer patients: an analysis using the National Cancer Data Base. J Natl Cancer Inst 2015; 107:dju491. [PMID: 25663688 DOI: 10.1093/jnci/dju491] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Randomized clinical trials showed that laparoscopic colectomy (LC) is superior to open colectomy (OC) in short-term surgical outcomes; however, the generalizability among real-world patients is not clear. METHODS The National Cancer Data Base was used to identify stage I-III colon cancer patients age 18 to 84 years in 2010 and 2011. A propensity score analysis with 1:1 matching (PS) was used to avoid the effect of treatment selection bias. Patients were clustered at the hospital level for multilevel regression analyses. The main outcomes measured were 30-day mortality, unplanned readmissions, length of stay (LOS), and initiation of adjuvant chemotherapy among stage III patients. All statistical tests were two-sided. RESULTS A total of 45 876 patients were analyzed, 18 717 (41%) LC and 27 159 (59%) OC. After PS matching, there were 18 230 patients in both groups and they were well balanced on their covariables. Compared with OC, LC showed consistent benefits in 30-day mortality (1.3% vs 2.3 %, odds ratio [OR] = 0.59, 95% confidence interval [CI] = 0.49 to 0.69, P < .001) and LOS (median 5 vs 6 days, incident rate ratio = 0.83, 95% CI = 0.8 to 0.84, P < .001). LC was also associated with a higher rate of adjuvant chemotherapy use in stage III patients (72.3% vs 67.0%, P < .001). LC was more likely to be performed by high-volume surgeons in high-volume hospitals, but there was no significant effect of the hospital/surgeon volume on short-term outcomes. CONCLUSION In routine clinical practice, laparoscopic colectomy is associated with lower 30-day mortality, shorter length of stay, and greater likelihood of adjuvant chemotherapy initiation among stage III colon cancer patients when compared with open colectomy.
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Affiliation(s)
- Zhiyuan Zheng
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (ZZ, AJ, CCL); Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (CYH, GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC).
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (ZZ, AJ, CCL); Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (CYH, GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC)
| | - Chun Chieh Lin
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (ZZ, AJ, CCL); Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (CYH, GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC)
| | - Chung-Yuan Hu
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (ZZ, AJ, CCL); Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (CYH, GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC)
| | - George J Chang
- Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, GA (ZZ, AJ, CCL); Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (CYH, GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC); Alliance for Clinical Trials in Oncology Network and American College of Surgeons Clinical Research Program, Chicago, IL (GJC)
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van Vugt JLA, Reisinger KW, Derikx JPM, Boerma D, Stoot JHMB. Improving the outcomes in oncological colorectal surgery. World J Gastroenterol 2014; 20:12445-12457. [PMID: 25253944 PMCID: PMC4168077 DOI: 10.3748/wjg.v20.i35.12445] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 03/18/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
During the last several decades, colorectal cancer surgery has experienced some major perioperative improvements. Preoperative risk-assessment of nutrition, frailty, and sarcopenia followed by interventions for patient optimization or an adapted surgical strategy, contributed to improved postoperative outcomes. Enhanced recovery programs or fast-track surgery also resulted in reduced length of hospital stay and overall complications without affecting patient safety. After an initially indecisive start due to uncertainty about oncological safety, the most significant improvement in intraoperative care was the introduction of laparoscopy. Laparoscopic surgery for colon and rectal cancer is associated with better short-term outcomes, whereas long-term outcomes regarding survival and recurrence rates are comparable. Nevertheless, long-term results in rectal surgery remain to be seen. Early recognition of anastomotic leakage remains a challenge, though multiple improvements have allowed better management of this complication.
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Impact of previous midline laparotomy on the outcomes of laparoscopic intestinal resections: a case-matched study. Surg Endosc 2014; 29:537-42. [DOI: 10.1007/s00464-014-3719-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/30/2014] [Indexed: 01/24/2023]
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Piccoli M, Agresta F, Trapani V, Nigro C, Pende V, Campanile FC, Vettoretto N, Belluco E, Bianchi PP, Cavaliere D, Ferulano G, La Torre F, Lirici MM, Rea R, Ricco G, Orsenigo E, Barlera S, Lettieri E, Romano GM, Ferulano G, Giuseppe F, La Torre F, Filippo LT, Lirici MM, Maria LM, Rea R, Roberto R, Ricco G, Gianni R, Orsenigo E, Elena O, Barlera S, Simona B, Lettieri E, Emanuele L, Romano GM, Maria RG. Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference. Int J Colorectal Dis 2014; 29:863-75. [PMID: 24820678 DOI: 10.1007/s00384-014-1887-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome. METHOD An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM). RESULTS AND CONCLUSION The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.
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Ptok H, Gastinger I, Bruns C, Lippert H. [Treatment reality with respect to laparoscopic surgery of colonic cancer in Germany]. Chirurg 2014; 85:583-92. [PMID: 24924639 DOI: 10.1007/s00104-014-2744-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- H Ptok
- An-Institut für Qualitätssicherung in der operativen Medizin gGmbH, Otto-von-Guericke Universität Magdeburg, Leipziger Str. 44, ZENIT II - Gebäude, 39120, Magdeburg, Deutschland,
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Annual case volume has no impact on patient outcomes in laparoscopic partial colectomy. Surg Endosc 2014; 28:1648-52. [PMID: 24442677 DOI: 10.1007/s00464-013-3365-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Surgeon case volume has been utilized in the credentialing process as a surrogate for surgeon skill. The purpose of this study was to compare objective outcome measures of laparoscopic partial colectomies performed by laparoscopically skilled surgeons with varying annual case census. METHODS We performed a retrospective cohort review of all patients (n = 255) undergoing elective laparoscopic partial colectomy. Patients were grouped according to surgeon's annual case volume as low annual case volume (LV; n = 48) and high annual case volume (HV; n = 207). HV is defined as performing >20 total cases and >25 cases per year. All demographic and clinical variables were evaluated with univariate logistic regression followed by a multivariate logistic regression model for variables approaching significance. RESULTS Demographic variables were found to be similar between groups. Only median estimated blood loss (100 vs. 150 mL for HV; p = 0.040) was found to be significantly different between groups. However, this was clinically insignificant, as it did not lead to an increased rate of blood transfusions (0.0 vs. 3.9 % for HV surgeons; p = 0.184). All other variables were similar in both univariate and multivariate logistic regression models. CONCLUSIONS Among surgeons with advanced laparoscopic training, the data suggest that LV surgeons are able to achieve similar outcomes as those who perform the operation routinely. Annual case volume should not be given undue emphasis when deciding whether to award privileges for laparoscopic partial colectomy.
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Kim MG, Kwon SJ. Comparison of the outcomes for laparoscopic gastrectomy performed by the same surgeon between a low-volume hospital and a high-volume center. Surg Endosc 2014; 28:1563-70. [DOI: 10.1007/s00464-013-3352-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 11/20/2013] [Indexed: 01/26/2023]
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Burns EM, Mamidanna R, Currie A, Bottle A, Aylin P, Darzi A, Faiz OD. The role of caseload in determining outcome following laparoscopic colorectal cancer resection: an observational study. Surg Endosc 2013; 28:134-42. [PMID: 24052341 DOI: 10.1007/s00464-013-3139-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/22/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection. METHODS All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission. RESULTS There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002-2003 and 2007-2008. In 2002-2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007-2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85-0.91), p < 0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04-1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04-1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission. CONCLUSION Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome. WHAT'S NEW IN THIS MANUSCRIPT This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.
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Affiliation(s)
- Elaine M Burns
- Department of Surgery, St Mary's Hospital, Imperial College, Praed Street, London, W2 1NY, UK,
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Regenbogen SE, Morris AM. Understanding Outcomes of Minimally Invasive Colorectal Resections. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Du XH, Shen D, Li R, Li SY, Ning N, Zhao YS, Zou ZY, Liu N. Robotic anterior resection of rectal cancer: technique and early outcome. Chin Med J (Engl) 2013; 126:51-54. [PMID: 23286477 DOI: 10.3760/cma.j.issn.0366-6999.20120994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2025] Open
Abstract
BACKGROUND The Da Vinci system is a newly developed device for colorectal surgery. With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Since conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the Da Vinci robotic system in anterior resections for rectal cancer. METHODS Between November 2010 and December 2011, a total of 22 patients affected by rectal cancer were operated on with robotic technique, using the Da Vinci robot. Data regarding the outcome and pathology reports were prospectively collected in a dedicated database. RESULTS There were no conversions to open surgery and no postoperative mortality of any patient. Mean operative time was (220 ± 46) minutes (range, 152 - 286 minutes). The median number of lymph nodes harvested was (14.6 ± 6.5) (range, 8 - 32), and the circumferential margin was negative in all cases. The distal margin was (2.6 ± 1.2) cm (range, 1.0 - 5.5 cm). The mean length of hospital stay was (7.8 ± 2.6) days (range, 7.0 - 13.0 days). Macroscopic grading of the specimen was complete in 19 cases and nearly complete in three patients. CONCLUSIONS Robotic anterior resection for rectal surgery is safe and feasible in experienced hands. Outcome and pathology findings are comparable with those observed in open and laparoscopy procedures. This technique may facilitate minimally invasive radical rectal surgery.
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Affiliation(s)
- Xiao-hui Du
- Department of General Surgery, People's Liberation Army General Hospital, Beijing 100853, China.
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Smith MD, Patterson E, Wahed AS, Belle SH, Courcoulas AP, Flum D, Khandelwal S, Mitchell JE, Pomp A, Pories WJ, Wolfe B. Can technical factors explain the volume-outcome relationship in gastric bypass surgery? Surg Obes Relat Dis 2012; 9:623-9. [PMID: 23274125 DOI: 10.1016/j.soard.2012.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 07/19/2012] [Accepted: 09/14/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND The existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship. OBJECTIVE The purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS. METHODS LABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors. RESULTS High-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone. CONCLUSION High-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.
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Abstract
Laparoscopic colorectal surgery may be comparable with open techniques when considering oncological and long-term follow-up outcomes; however, there are a few operative complications specific to laparoscopic colorectal surgery. This article reviews the array of complications and discusses them in detail.
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Abstract
The role of laparoscopic proctectomy in rectal cancer has not clearly been defined. Publications on long-term outcomes after laparoscopic proctectomy is lacking and there is a wide variation of practice patterns of rectal cancer management. Current data supports the feasibility of laparoscopic proctectomy for rectal cancer but due to surgeon, patient and tumor related factors open technique may be favored. Current series suggest that laparoscopic proctectomy can be performed with similar oncologic adequacy with regards to, circumferential resection margin, distal margin, local recurrence and quality of life. Ongoing trials will provide evidence clarifying the role of laparoscopic proctectomy in rectal cancer. Until then, high-level laparoscopic skills and meticulous preoperative evaluation of both patient and tumor can identify appropriate candidates.
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Should laparoscopic colorectal surgery still be considered unsafe? Ann Surg 2012; 255:e22; author reply e23. [PMID: 22470081 DOI: 10.1097/sla.0b013e3182508bc4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon's specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012; 2012:CD005391. [PMID: 22419309 PMCID: PMC12076000 DOI: 10.1002/14651858.cd005391.pub3] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer. OBJECTIVES To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses. MAIN RESULTS Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively). AUTHORS' CONCLUSIONS The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.
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Affiliation(s)
- David Archampong
- Department of Surgery, University Hospital Wales, Cardiff, Wales, UK.
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Anwar S, Fraser S, Hill J. Surgical specialization and training - its relation to clinical outcome for colorectal cancer surgery. J Eval Clin Pract 2012; 18:5-11. [PMID: 20704632 DOI: 10.1111/j.1365-2753.2010.01525.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Surgical sub-specialization has been considered to be a major factor in improving cancer surgery-related outcomes in terms of 5-year survival and disease-free intervals. In this article we have looked at the evidence supporting the improvement in colorectal cancer outcomes with 'colorectal specialists' performing colon and rectal surgery. METHODS A literature review was carried out using search engines such as Pubmed, Ovid and Cochrane Databases. Only studies looking at colorectal cancer outcome related to surgery were included in our review. RESULTS Specialist surgeons performing a high volume of colorectal cancer surgery demonstrated better 5-year survival rates in patients, with less local recurrence. This was most evident in surgery for rectal cancer, where an association with increased sphincter saving surgery was also seen. Total mesorectal excision is now the accepted treatment for rectal cancer and has markedly improved survival rates and decreased local recurrence. CONCLUSION The outcomes in colorectal surgery continue to steadily improve. The training of specialized colorectal surgeons is a major contributing factor towards this improvement.
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Affiliation(s)
- Suhail Anwar
- Department of General Surgery, Huddersfield Royal Infirmary, Huddersfield, UK.
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Cost of laparoscopy and laparotomy in the surgical treatment of colorectal cancer. Surg Endosc 2011; 26:1444-53. [DOI: 10.1007/s00464-011-2053-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/27/2011] [Indexed: 12/22/2022]
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Mroczkowski P, Kube R, Ptok H, Schmidt U, Hac S, Köckerling F, Gastinger I, Lippert H. Low-volume centre vs high-volume: the role of a quality assurance programme in colon cancer surgery. Colorectal Dis 2011; 13:e276-83. [PMID: 21689348 DOI: 10.1111/j.1463-1318.2011.02680.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume. METHOD Data were used from an observational study to determine whether outcomes of colon cancer surgery are related to hospital volume. Hospitals were divided into three groups (low, medium and high) based on annual caseload. Cancer staging, resected lymph nodes, perioperative complications and follow up were monitored. Between 2000 and 2004, 345 hospitals entered 31,261 patients into the study: 202 hospitals (group I) were classified as low volume (<30 operations; 7760 patients; 24.8%), 111 (group II) as medium volume (30-60; 14,008 patients; 44.8%) and 32 (groups III) as high volume (>60; 9493 patients; 30.4%). RESULTS High-volume centres treated more patients in UICC stages 0, I and IV, whereas low-volume centres treated more in stages II and III (P<0.001). There was no significant difference for intra-operative complications and anastomotic leakage. The difference in 30-day mortality between the low and high-volume groups was 0.8% (P=0.023).Local recurrence at 5 years was highest in the medium group. Overall survival was highest in the high-volume group; however, the difference was only significant between the medium and high-volume groups. For the low and high-volume groups, there was no significant difference in the 5-year overall survival rates. CONCLUSION A definitive statement on outcome differences between low-volume and high-volume centres participating in a quality assurance programme cannot be made because of the heterogeneity of results and levels of significance. Studies on volume-outcome effects should be regarded critically.
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Affiliation(s)
- P Mroczkowski
- Department of General, Visceral and Vascular Surgery, Otto-von-Guericke-University of Magdeburg, Magdeburg, Germany.
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Moran DC, Kavanagh DO, Nugent E, Swan N, Eguare E, O'Riordain D, Keane FBV, Neary PC. Laparoscopic resection for low rectal cancer: evaluation of oncological efficacy. Int J Colorectal Dis 2011; 26:1143-9. [PMID: 21547356 DOI: 10.1007/s00384-011-1221-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Laparoscopic resection of low rectal cancer poses significant technical difficulties for the surgeon. There is a lack of published follow-up data in relation to the surgical, oncological and survival outcomes in these patients. AIM The aim of this study is to evaluate the surgical, oncological and survival outcomes in all patients undergoing laparoscopic resection for low rectal cancer. METHODS Consecutive patients undergoing laparoscopic resection for low rectal cancers were included in the study. Clinical, pathological and follow-up data were recorded over a 4-year period. The mean follow-up was 25 months RESULTS A total of 53 patients were included in the study, 30 of whom were males. The mean age was 64.14 years (range, 34-86 years). The mean hospital stay was 8.2 days (range, 4-42 days). Fifty were completed laparoscopically and three were converted to an open procedure. Thirty-eight were anterior resections and 15 were abdominoperineal resections. Twenty-four patients received neoadjuvant chemoradiotherapy. The total mesorectal excision was optimal in 51 (98%) cases. There were no anastomotic sequelae and no surgical mortality. There was no local recurrence detected. The overall survival (mean follow-up, 25 months) was 93.5%. CONCLUSION Laparoscopic resection for low rectal cancers permits optimum oncological control. In our series, this technical approach is associated with excellent 4-year survival and clinical outcomes.
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Affiliation(s)
- Diarmaid C Moran
- Division of Colorectal Surgery, Minimally Invasive Surgery, AMNCH, Tallaght, Dublin, 24, Ireland.
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