|
1
|
Klebaner D, Brown E, Fisher GA, Shelton A, Johnson TP, Shaheen S, Chen C, Heestand G, Holden T, Bien J, King DA, Dawes AJ, Morris AM, Kirilcuk N, Kin C, Gahagan J, Sheth V, Ghanouni P, Richter S, Vitzthum L, Rahimy E, Chang DT, Pollom EL. Phase II trial of organ preservation program using short-course radiation and FOLFOXIRI for rectal cancer (SHORT-FOX): Two-Year primary outcome analysis. Radiother Oncol 2025; 207:110884. [PMID: 40209856 DOI: 10.1016/j.radonc.2025.110884] [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: 12/16/2024] [Revised: 03/31/2025] [Accepted: 04/01/2025] [Indexed: 04/12/2025]
Abstract
BACKGROUND AND PURPOSE As patients with rectal cancer with clinical complete response (cCR) after neoadjuvant therapy may be safely spared Total Mesorectal Excision (TME), strategies to maximize cCR are needed. MATERIALS AND METHODS We conducted a single-arm phase II study to determine whether dose-escalated short-course radiotherapy (25 Gy/5 fractions + 5 Gy/1 fraction boost) followed by eight cycles of FOLFOXIRI increased cCR rates among adult patients with > T2N0M0 or low T2N0 rectal cancer. RESULTS Between 2020 and 2023, we enrolled 37 patients, of whom 27 (73 %) had at least one high-risk feature (cT4, extramural vascular invasion [EMVI], N2, threatened circumferential resection margin, positive lateral node). At primary endpoint assessment, nine (24 %) patients had cCR on both endoscopy and MRI, and pursued organ preservation (OP). Fourteen (38 %) patients had cCR only on endoscopy, nine of whom pursued OP. Of the 18 patients who pursued OP, nine had local regrowth at two years from radiotherapy start, with two-year TME-free survival of 26 %. Baseline factors significantly associated with not achieving OP included age < 50 years and T4 disease. At mid-treatment restaging, patients who achieved OP were significantly less likely to have persistent node positivity, EMVI, and endoscopically visible tumor. Grade 3+ adverse events at least possibly attributed to chemotherapy and radiotherapy occured in 51% and 43% of patients, respectively. CONCLUSION Short-course radiotherapy with a boost followed by FOLFIXIRI results in OP in one-quarter of patients with high-risk rectal cancer, with poorer response among younger patients and T4 disease. Mid-treatment response may help guide timely decision-making regarding treatment.
Collapse
Affiliation(s)
- Daniella Klebaner
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States
| | - Eleanor Brown
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States
| | - George A Fisher
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Andrew Shelton
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Tyler P Johnson
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Shagufta Shaheen
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Christopher Chen
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Gregory Heestand
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Thomas Holden
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Jeffrey Bien
- Department of Oncology and Hematology, Kaiser Permanente, Santa Clara, CA, United States
| | - Daniel A King
- Department of Medical Oncology, Northwell Health, New Hyde Park, NY, United States
| | - Aaron J Dawes
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Arden M Morris
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Natalie Kirilcuk
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Cindy Kin
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - John Gahagan
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Vipul Sheth
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Pejman Ghanouni
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Sara Richter
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States
| | - Lucas Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States
| | - Elham Rahimy
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, CA, United States.
| |
Collapse
|
|
2
|
Murshed I, Bunjo Z, Seow W, Murshed I, Bedrikovetski S, Thomas M, Sammour T. Economic Evaluation of 'Watch and Wait' Following Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review. Ann Surg Oncol 2025; 32:137-157. [PMID: 39181996 PMCID: PMC11659367 DOI: 10.1245/s10434-024-16056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 08/05/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Owing to multimodal treatment and complex surgery, locally advanced rectal cancer (LARC) exerts a large healthcare burden. Watch and wait (W&W) may be cost saving by removing the need for surgery and inpatient care. This systematic review seeks to identify the economic impact of W&W, compared with standard care, in patients achieving a complete clinical response (cCR) following neoadjuvant therapy for LARC. METHODS The PubMed, OVID Medline, OVID Embase, and Cochrane CENTRAL databases were systematically searched from inception to 26 April 2024. All economic evaluations (EEs) that compared W&W with standard care were included. Reporting and methodological quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), BMJ and Philips checklists. Narrative synthesis was performed. Primary and secondary outcomes were (incremental) cost-effectiveness ratios and the net financial cost. RESULTS Of 1548 studies identified, 27 were assessed for full-text eligibility and 12 studies from eight countries (2016-2024) were included. Seven cost-effectiveness analyses (complete EEs) and five cost analyses (partial EEs) utilized model-based (n = 7) or trial-based (n = 5) analytics with significant variations in methodological design and reporting quality. W&W showed consistent cost effectiveness (n = 7) and cost saving (n = 12) compared with surgery from third-party payer and patient perspectives. Critical parameters identified by uncertainty analysis were rates of local and distant recurrence in W&W, salvage surgery, perioperative mortality and utilities assigned to W&W and surgery. CONCLUSION Despite heterogenous methodological design and reporting quality, W&W is likely to be cost effective and cost saving compared with standard care following cCR in LARC. Clinical Trials Registration PROSPERO CRD42024513874.
Collapse
Affiliation(s)
- Ishraq Murshed
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Zachary Bunjo
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Warren Seow
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Ishmam Murshed
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michelle Thomas
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| |
Collapse
|
|
3
|
Bakillah E, Sharpe J, Wirtalla C, Goldberg D, Altieri MS, Aarons CB, Keele LJ, Kelz RR. Minimally invasive colorectal cancer surgery: an observational study of medicare advantage and fee-for-service beneficiaries. Surg Endosc 2024; 38:6800-6811. [PMID: 39160311 PMCID: PMC11525327 DOI: 10.1007/s00464-024-11168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Enrollment of Medicare beneficiaries in medicare advantage (MA) plans has been steadily increasing. Prior research has shown differences in healthcare access and outcomes based on Medicare enrollment status. This study sought to compare utilization of minimally invasive colorectal cancer (CRC) surgery and postoperative outcomes between MA and Fee-for-Service (FFS) beneficiaries. METHODS A retrospective cohort study of beneficiaries ≥ 65.5 years of age enrolled in FFS and MA plans was performed of patients undergoing a CRC resection from 2016 to 2019. The primary outcome was operative approach, defined as minimally invasive (laparoscopic) or open. Secondary outcomes included robotic assistance, hospital length-of-stay, mortality, discharge disposition, and hospital readmission. Using balancing weights, we performed a tapered analysis to examine outcomes with adjustment for potential confounders. RESULTS MA beneficiaries were less likely to have lymph node (12.9 vs 14.4%, p < 0.001) or distant metastases (15.5% vs 17.0%, p < 0.001), and less likely to receive chemotherapy (6.2% vs 6.7%, p < 0.001), compared to FFS beneficiaries. MA beneficiaries had a higher risk-adjusted likelihood of undergoing laparoscopic CRC resection (OR 1.12 (1.10-1.15), p < 0.001), and similar rates of robotic assistance (OR 1.00 (0.97-1.03), p = 0.912), compared to FFS beneficiaries. There were no differences in risk-adjusted length-of-stay (β coefficient 0.03 (- 0.05-0.10), p = 0.461) or mortality at 30-60-and 90-days (OR 0.99 (0.95-1.04), p = 0.787; OR 1.00 (0.96-1.04), p = 0.815; OR 0.98 (0.95-1.02), p = 0.380). MA beneficiaries had a lower likelihood of non-routine disposition (OR 0.77 (0.75-0.78), p < 0.001) and readmission at 30-60-and 90-days (OR 0.76 (0.73-0.80), p < 0.001; OR 0.78 (0.75-0.81), p < 0.001; OR 0.79 (0.76-0.81), p < 0.001). CONCLUSIONS MA beneficiaries had less advanced disease at the time of CRC resection and a greater likelihood of undergoing a laparoscopic procedure. MA enrollment is associated with improved health outcomes for elderly beneficiaries undergoing operative treatment for CRC.
Collapse
Affiliation(s)
- Emna Bakillah
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA.
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - James Sharpe
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Chris Wirtalla
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Drew Goldberg
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Maria S Altieri
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Cary B Aarons
- Department of Surgery, Columbia University, New York, NY, USA
| | - Luke J Keele
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA, 19104, USA
- Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
|
4
|
Katsura M, Ashbrook M, Ikenoue T, Takahashi K, Ito MA, Martin MJ, Inaba K, Matsushima K. Surgical trends and outcomes of open, laparoscopic, and robotic colostomy reversal for benign disease. Surgery 2024; 176:1366-1373. [PMID: 39179435 DOI: 10.1016/j.surg.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/05/2024] [Accepted: 07/18/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Despite the increasing use of minimally invasive surgeries, the outcome benefits of adopting minimally invasive surgery for colostomy reversal remain unclear. We aimed to analyze nationwide trends in the use of minimally invasive surgery for colostomy reversal and compare patient outcomes between different surgical approaches. METHODS The National Inpatient Sample was queried for patients who underwent colostomy reversal for benign disease from 2015 to 2021. National trends in the use of minimally invasive surgery for colostomy reversal were analyzed by Cochran-Armitage tests. Multivariable linear and logistic regressions accounting for hospital sample weights were developed to examine the association between operative approach (open, laparoscopic, and robotic) and patient outcomes, including hospital complications, length of stay, and hospital charges. RESULTS A total of 23,260 patients underwent colostomy reversal: 18,880 (81.2%) open, 3,245 (14.0%) laparoscopic, and 1,135 (4.9%) robotic surgery. From 2015 to 2021, the proportion of robotic approaches increased >5-fold (range 2.1-12.5%; Ptrend < .001), whereas the increase in laparoscopic approaches was not significant (range 11.5-16.2%; Ptrend = .34). Multivariable analysis showed that the laparoscopic approach was associated with a lower incidence of pulmonary complications (adjusted odds ratio, 0.49; 95% confidence interval, 0.28-0.87), surgical-site infection (odds ratio, 0.37; 95% CI, 0.19-0.72), peritonitis/abdominal abscess (odds ratio, 0.45; 95% confidence interval, 0.26-0.78), and paralytic ileus (odds ratio, 0.67; 95% confidence interval, 0.48-0.92). The robotic approach was associated with a lower incidence of paralytic ileus (odds ratio, 0.58; 95% confidence interval, 0.33-0.99). Laparoscopic and robotic approaches were associated with 22.9% and 29.9% shorter length of stay, respectively. The robotic approach was associated with 33.0% greater hospital charge. CONCLUSIONS This study observed a significant trend toward the increased use of robotics in colostomy reversal and potential clinical benefits with minimally invasive surgery. Robotic colostomy reversal, along with laparoscopic approach, may provide better postoperative recovery compared with the open approach; however, the utility of robotic surgeries needs to be reevaluated in the future, given the limited clinical benefits despite greater hospital charges.
Collapse
Affiliation(s)
- Morihiro Katsura
- Department of Surgery, University of Southern California, Los Angeles, CA. https://twitter.com/hiro_m_bj8
| | - Matthew Ashbrook
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Tatsuyoshi Ikenoue
- Data Science and AI Innovation Research Promotion Centre, Shiga University, Hikone, Shiga, Japan
| | - Kyosuke Takahashi
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Masaki A Ito
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Matthew J Martin
- Department of Surgery, University of Southern California, Los Angeles, CA. https://twitter.com/docmartin22
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA
| | | |
Collapse
|
|
5
|
Dai B, Yang LW, Yi H, Jing GM. Robotic versus laparoscopic abdominoperineal resection for patients with rectal cancer. Asian J Surg 2024; 47:3966-3967. [PMID: 38724370 DOI: 10.1016/j.asjsur.2024.04.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/19/2024] [Accepted: 04/25/2024] [Indexed: 09/05/2024] Open
Affiliation(s)
- Bo Dai
- Department of General Surgery, Chongqing Hospital of Jiangsu Province Hospital, 401420, China; The People's Hospital of Qijiang District, Chongqing, 401420, China
| | - Lin-Wen Yang
- Clinical Medicine Department of North Sichuan Medical College, China
| | - Hong Yi
- Department of Oncology, People's Hospital Affiliated to Chongqing Three Gorges Medical College, Chongqing, 404000, China
| | - Guo-Min Jing
- Clinical Medicine Department of North Sichuan Medical College, China.
| |
Collapse
|
|
6
|
Weigl MP, Attenberger C, Feurstein B, Jäger T, Emmanuel K, Clemens P, Mink S, Kowatsch M, Königsrainer I, Tschann P. Enhanced recovery and reduced conversion rates in robotic rectal cancer surgery: a single-center retrospective cohort study. Langenbecks Arch Surg 2024; 409:264. [PMID: 39207562 DOI: 10.1007/s00423-024-03453-2] [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: 07/09/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE This study aimed to compare the outcomes of robotic-assisted rectal resection with conventional laparoscopic and open approaches, focusing on complication rates, conversion rates, length of hospital stay, and oncologic outcomes. METHODS A retrospective single-center cohort study included 106 patients with non-metastatic rectal cancer (UICC stages I-III) who underwent rectal resection from January 2013 to December 2023. Patients were assigned to open surgery (n = 23), conventional laparoscopic surgery (n = 55), or robotic-assisted surgery (n = 28). RESULTS Robotic surgery demonstrated significantly lower conversion rates compared to minimal-invasive surgeries (p = 0.047) and shorter hospital stays (11.5 ± 8 days) compared to open (17.91 ± 12 days) and laparoscopic (17.2 ± 14 days) surgeries (p = 0.001). The quality of the specimen was significantly better (Score 1) in robotic (85.71%) and open (89.09%) cases compared to laparoscopic approaches (47.83%) (p < 0.001). Laparoscopic surgery was identified as a risk factor for worse specimen quality (p < 0.001). Older patients (> 63 years) had a higher risk for conversion in univariate analysis (p = 0.049). Morbidity was comparable between the groups (p = 0.131), and the anastomotic leakage rate did not differ significantly (laparoscopic: 18.18%, open: 13.04%, robotic: 17.86%). Kaplan-Meier survival curves showed no significant differences in overall survival probabilities among the groups. CONCLUSION Robotic-assisted rectal resection provides significant advantages in terms of lower conversion rates, better specimen quality, and shorter hospital stays while maintaining comparable complication rates and oncologic outcomes to conventional laparoscopic and open approaches. These findings support robotic surgery as a standard treatment option for rectal cancer.
Collapse
Affiliation(s)
- Markus P Weigl
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Christian Attenberger
- Private University in the Principality of Liechtenstein (UFL), Triesen, Principality of Liechtenstein
- Institute of Medical Physics, Academic Teaching Hospital, Feldkirch, Austria
| | - Benedikt Feurstein
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Tarkan Jäger
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Patrick Clemens
- Department of Radio-Oncology, Academic Teaching Hospital, Feldkirch, Austria
| | - Sylvia Mink
- Private University in the Principality of Liechtenstein (UFL), Triesen, Principality of Liechtenstein
- Central Medical Laboratories, Feldkirch, Austria
| | - Matthias Kowatsch
- Private University in the Principality of Liechtenstein (UFL), Triesen, Principality of Liechtenstein
| | - Ingmar Königsrainer
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Peter Tschann
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria.
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria.
| |
Collapse
|
|
7
|
Lavie JL, Guidry RF, Palines PA, Dibbs RP, Melancon DM, Womac DJ, Stalder MW. The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction. Ann Plast Surg 2024; 93:239-245. [PMID: 39023410 DOI: 10.1097/sap.0000000000004021] [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: 07/20/2024]
Abstract
BACKGROUND Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. METHODS After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. RESULTS Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. CONCLUSIONS vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.
Collapse
Affiliation(s)
- Jennifer L Lavie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Richard F Guidry
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Patrick A Palines
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Rami P Dibbs
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Daniel J Womac
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | | |
Collapse
|
|
8
|
Song L, Xu WQ, Wei ZQ, Tang G. Robotic vs laparoscopic abdominoperineal resection for rectal cancer: A propensity score matching cohort study and meta-analysis. World J Gastrointest Surg 2024; 16:1280-1290. [PMID: 38817290 PMCID: PMC11135314 DOI: 10.4240/wjgs.v16.i5.1280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/29/2024] [Accepted: 04/10/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Robotic surgery (RS) is gaining popularity; however, evidence for abdominoperineal resection (APR) of rectal cancer (RC) is scarce. AIM To compare the efficacy of RS and laparoscopic surgery (LS) in APR for RC. METHODS We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022. Data regarding short-term surgical outcomes were compared between the two groups. To reduce the effect of potential confounding factors, propensity score matching was used, with a 1:1 ratio between the RS and LS groups. A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery. RESULTS Of 133 patients, after propensity score matching, there were 42 patients in each group. The postoperative complication rate was significantly lower in the RS group (17/42, 40.5%) than in the LS group (27/42, 64.3%) (P = 0.029). There was no significant difference in operative time (P = 0.564), intraoperative transfusion (P = 0.314), reoperation rate (P = 0.314), lymph nodes harvested (P = 0.309), or circumferential resection margin (CRM) positive rate (P = 0.314) between the two groups. The meta-analysis showed patients in the RS group had fewer positive CRMs (P = 0.04), lesser estimated blood loss (P < 0.00001), shorter postoperative hospital stays (P = 0.02), and fewer postoperative complications (P = 0.002) than patients in the LS group. CONCLUSION Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.
Collapse
Affiliation(s)
- Li Song
- Department of Gastrointestinal Surgery, Chengdu Fifth People's Hospital, Chengdu 610000, Sichuan Province, China
| | - Wen-Qiong Xu
- Department of Nephrology, Chengdu Fifth People's Hospital, Chengdu 610000, Sichuan Province, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400000, China
| | - Gang Tang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
|
9
|
Yang H, Zhou L. The urinary and sexual outcomes of robot-assisted versus laparoscopic rectal cancer surgery: a systematic review and meta-analysis. Surg Today 2024; 54:397-406. [PMID: 36943447 DOI: 10.1007/s00595-023-02671-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/21/2023] [Indexed: 03/23/2023]
Abstract
To compare the urinary and sexual outcomes between robot-assisted rectal cancer (RC) surgery (RRCS) and laparoscopic RC surgery (LRCS) using a meta-analysis, searches were conducted of the Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases. The International Prostate Symptom Score (IPSS) was the primary outcome. Eleven studies (790 patients with RRCS and 888 with LRCS) were included. The IPSS scores were significantly lower for RRCS than LRCS from baseline to 3 months (weighted mean difference [WMD] = - 1.21, 95% confidence interval [CI]: - 1.8,-0.62, I2 = 89.9%), to 6 months (WMD = - 1.13, 95% CI: - 1.74, - 0.52, I2 = 93.3%), and to 12 months (WMD = - 0.93, 95% CI: - 1.59, - 0.26, I2 = 93.8%). The International Index of Erectile Function (IIEF) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 3.36, 95% CI: 1.28, 5.44, I2 = 92.7%). The female sexual function index (FSFI) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 1.31, 95% CI: 0.87, 1.76, I2 = 0), to 6 months (WMD = 2.36, 95% CI: 1.93, 2.79, I2 = 24.3%), and to 12 months (WMD = 1.67, 95% CI: 0.41, 2.93, I2 = 90.9%). RRCS also achieved a better recovery of the urological and sexual function than LRCS for patients with RC. Larger-scale prospective randomized control trials are needed to verify these results.
Collapse
Affiliation(s)
- Hua Yang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Lei Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, China.
| |
Collapse
|
|
10
|
Wang Y, Ali M, Sun Q, Wang W, Ren J, Wang L, Wang D. Radial resection margin distinguishes between superficial versus deep resection in colorectal cancer: a retrospective study. J Robot Surg 2024; 18:60. [PMID: 38289524 DOI: 10.1007/s11701-024-01836-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
Randomized studies showed that robotic surgery was short-term useful and safe for cancer patients. We investigated whether robots improve deep resection margins or superficial resection margins for radial resection margins in terms of short-term results. From an institutional database, we selected all superficial groups (≤ 3 mm) and deeper groups (≥ 4 mm) with rectal cancer treated with resection for a year. We evaluated the short-term post-operative 90-day outcomes on a radial resection size-based margin differentiation, including the first bowel movement, length of hospital stay, sepsis, and harvested lymph node. The main results were grades III-IV on the Clavien-Dindo scale and complications. We found 120 patients who had oncologic resection of rectal cancer; 42 patients with a superficial radial resection margin of ≤ 3 mm, all the following outcomes improved: the harvested lymph node, proximal resection margin, TME, flatus time, liquid diet duration, anastomotic leakage, and sepsis. Among these advantages were a reduced risk of metastasis and an overall reduction in local recurrence.
Collapse
Affiliation(s)
- Yang Wang
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Muhammad Ali
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Qiannan Sun
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Wei Wang
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Jun Ren
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Liuhua Wang
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Daorong Wang
- Medical College of Yangzhou University, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China.
- Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, Jiangsu, 225001, People's Republic of China.
- Department of General Surgery, General Surgery Institute of Yangzhou, Northern Jiangsu People's Hospital, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China.
| |
Collapse
|
|
11
|
Mao J, Genkinger JM, Rundle AG, Wright JD, Aryal S, Liebeskind AY, Tehranifar P. Racial and Ethnic Disparities in the Use of Robot-Assisted Surgery and Minimally Invasive Surgery in Pelvic Cancer Treatment: A Systematic Review. Cancer Epidemiol Biomarkers Prev 2024; 33:20-32. [PMID: 37870412 DOI: 10.1158/1055-9965.epi-23-0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/26/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023] Open
Abstract
Surgical innovations for cancer treatment may penetrate differentially across racial and ethnic groups and contribute to disparities in health and health care quality. We summarized the current evidence of racial and ethnic disparities in robot-assisted surgery (RAS) and minimally invasive surgery (MIS) use in four major pelvic cancer treatments. We identified studies related to racial and ethnic disparities in RAS and/or MIS use in the treatment of prostate, endometrial, bladder, and rectal cancers during 2001 to 2022 from PubMed, EMBASE, and the Cochrane database. Twenty-eight studies were selected (prostate = 7, endometrial = 14, bladder = 1, rectal = 5, multiple cancers = 1) and all were retrospective. Thirteen and 23 studies examined racial and ethnic differences in individual patients' receipt of RAS and MIS, respectively. Black patients were less likely to receive RAS/MIS than White patients in most studies. Hispanic patients were less likely to receive RAS/MIS than White patients in just over half of the studies. Studies of Asian patients were few and reported mixed results. Three studies examined disparities on the center level and found that racial and ethnic minority prostate cancer patients were less likely to be treated at RAS-performing or high-technology facilities. More work is needed to improve understanding of the mechanisms underlying racial and ethnic disparities in RAS and MIS use and their impact on disparities in health outcomes.
Collapse
Affiliation(s)
- Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Jeanine M Genkinger
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Andrew G Rundle
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Suvekshya Aryal
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | | | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| |
Collapse
|
|
12
|
Nekkanti SS, Jajoo B, Mohan A, Vasudevan L, Peelay Z, Kazi M, Desouza A, Saklani A. Empty pelvis syndrome: a retrospective audit from a tertiary cancer center. Langenbecks Arch Surg 2023; 408:331. [PMID: 37615748 DOI: 10.1007/s00423-023-03069-y] [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: 12/10/2022] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Empty pelvis syndrome (EPS) has been defined as a complications arising as a sequel of empty space created after extensive pelvic surgery involving perineal resection. However this definition has been heterogenous throughout the limited literature available. Hence, EPS is a significant yet under recognized complication vexing both patients and surgeons. Even till date, prevention and management of EPS remain a challenge. Various preventive strategies have been employed each with its own complications. Few small studies mentioned incidence of this dreaded complication in between 20 and 40%. But most of these studies quote vague evidence and especially only after TPE surgeries. To the best of our knowledge, incidence after APR and PE has never been mentioned in literature. PURPOSE To assess the clinical burden of empty pelvis syndrome in patients undergoing abdominoperineal resection (APR), posterior exenteration (PE), or total pelvic exenteration (TPE) for low rectal cancers. METHODS This is a retrospective audit from a high-volume tertiary cancer center in India. Patients who underwent APR, PE, or TPE between the years 2013 to 2021 were screened and analyzed for incidence, presentation, and management of empty pelvic syndrome (EPS). RESULTS A total of 1224 patients' electronic medical records were screened for complications related to empty pelvis. The overall incidence of EPS was 95/1224 (7%) with 55/1024 (5%) in APR, 8/39 (20.5%) in PE, and 32/143 (21.9%) in TPE. The most common clinical presentation was small bowel obstruction 43/95 (45.2%) and most presented late, 56/95 (60%), i.e., after 30 days of surgery. Most of the patients who had EPS were managed conservatively 55/95 (57%). CONCLUSION EPS is a significant clinical problem that can lead to major morbidity, especially after exenterative surgeries warranting effective preventive strategies.
Collapse
Affiliation(s)
- Sri Siddhartha Nekkanti
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Bhushan Jajoo
- Siddharth Gupta Memorial Cancer Hospital, Sawangi, Wardha, Maharastra, 442001, India
| | - Anand Mohan
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Lakshanya Vasudevan
- Department of Clinical Research, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Zoya Peelay
- Department of Clinical Research, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Mufaddal Kazi
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Department of Gastrointestinal Oncology, Colorectal Division, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
| |
Collapse
|
|
13
|
Hayden DM, Korous KM, Brooks E, Tuuhetaufa F, King-Mullins EM, Martin AM, Grimes C, Rogers CR. Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2023; 37:3306-3320. [PMID: 36520224 PMCID: PMC10947550 DOI: 10.1007/s00464-022-09793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.
Collapse
Affiliation(s)
- Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin M Korous
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA
| | - Ellen Brooks
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | - Fa Tuuhetaufa
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | | | - Abigail M Martin
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chassidy Grimes
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Charles R Rogers
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA.
| |
Collapse
|
|
14
|
Predictive value of the Naples prognostic score on postoperative outcomes in patients with rectal cancer. Langenbecks Arch Surg 2023; 408:113. [PMID: 36859650 DOI: 10.1007/s00423-023-02851-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/21/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE The Naples prognostic score (NPS) is a prognostic index based on the nutritional and inflammatory status. However, its utility in predicting postoperative complications (POCs) has not been examined in rectal cancer (RC). We evaluated the predictive value of the preoperative NPS for POCs in RC. METHODS We retrospectively analyzed 235 patients who underwent surgery for RC. The NPS was calculated based on serum albumin, serum total cholesterol, the neutrophil-to-lymphocyte ratio (NLR) and the lymphocyte-to-monocyte ratio (LMR). Severe POCs were defined as Clavien-Dindo classification grade ≥ III. The optimal cut-off value of the NPS was determined by a receiver operator characteristic (ROC) curve analysis. The NPS, NLR, LMR, platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP)-to-albumin ratio (CAR), Glasgow prognostic score (GPS), Onodera prognostic nutritional index (PNI) and controlling nutritional status score (CONUT) were investigated as inflammation-based and/or nutritional markers. Predictors of severe POCs were analyzed by logistic regression modeling. RESULTS Severe POCs were observed in 64 patients (27.2%). Male sex, operation time (> 257 min), blood loss (≥ 30 mL), albumin (< 4.0 g/dL), CRP (≥ 1.0 mg/dL), total cholesterol (≤ 180 mg/dL), NPS (≥ 2), LMR (≥ 3.48), PLR (≥ 103.6), CAR (> 0.025), GPS (≥ 1), PNI (< 48.1) and CONUT (≥ 2) were significantly associated with severe POCs. The multivariate analysis revealed that male sex, operation time (> 257 min), and a high NPS (≥ 2) were independent predictors of severe POCs. The ROC curve analysis revealed that the NPS had the greatest predictive value among the inflammation-based and/or nutritional markers. CONCLUSION The NPS is a valuable predictor of severe POCs in RC.
Collapse
|
|
15
|
Seniority of the assistant surgeon and perioperative outcomes in robotic-assisted proctectomy for rectal cancer. J Robot Surg 2022; 17:1097-1104. [PMID: 36586036 DOI: 10.1007/s11701-022-01515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 12/25/2022] [Indexed: 01/01/2023]
Abstract
The background of this study is to evaluate the impact of the assistant surgeon's in robotic-assisted proctectomy (RAP) on perioperative outcomes. A retrospective analysis of all patients who underwent RAP for rectal adenocarcinoma between 2011 and 2020 was conducted. Patient cohort was divided into three groups based on the assistant surgeon's training level: post-graduate years (PGY) 1-3 surgical residents (Group 1), PGY 4-5 surgical residents (Group 2), and board-certified general surgeons (Group 3). Overall, 175 patients were included in the study: 29 patients (17%) in Group 1, 84 (48%) in Group 2, and 62 (35%) in Group 3. The median tumor distance from the anal verge was 8 cm in all groups (p = 0.73). The median operative time was similar across all groups: 290, 291, and 281 min in Groups 1, 2, and 3, respectively (p = 0.69). In a multivariable analysis, the lack of association between assistant training level and procedure time maintained when adjusting for the year of operation (p = 0.84). Patients operated with junior residents as assistant surgeons (Group 1) had a more postoperative complications (p = 0.01) and a slightly longer hospital length of stay [7 days, interquartile range (IQR) 3], compared to those operated by assistant surgeons that were senior residents or attendings (6 IQR 2.5, and 6 IQR 2 in Groups 2 and 3, respectively; p = 0.02). Conversion rates (p = 0.12), intraoperative complications (p = 0.39), major postoperative complications (Clavien-Dindo ≥ 3; p = 0.32), 30-day readmission (p = 0.45), and mortality (p = 0.99) were similar between the groups. Robotic-assisted proctectomy performed with the assistance of a junior resident was found to be correlated with worse postoperative outcomes compared to more experienced assistants. No difference was seen in intraoperative outcomes.
Collapse
|
|
16
|
Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula. Surg Res Pract 2022; 2022:9242813. [DOI: 10.1155/2022/9242813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46,
) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min,
). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%,
) but a decrease in conversion rate (8.1% vs. 13.8%,
) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min,
) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%,
) and between laparoscopic and robotic approaches (2.8% vs. 3.8%,
). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.
Collapse
|
|
17
|
Outcomes and Cost Analysis of Robotic Versus Laparoscopic Abdominoperineal Resection for Rectal Cancer: A Case-Matched Study. Dis Colon Rectum 2022; 65:1279-1286. [PMID: 35195554 DOI: 10.1097/dcr.0000000000002394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although laparoscopy for abdominoperineal resection has been well defined, the literature lacks comparative studies on robotic abdominoperineal resection. Because robotic abdominoperineal resections typically do not require splenic mobilization or an anastomosis for reconstruction, the mean console time is expected to be shorter than low anterior resection. We hypothesized that robotic and laparoscopic abdominoperineal resection would provide similar oncologic and financial outcomes. OBJECTIVE The study aimed to compare the perioperative, oncologic, and economic outcomes of the robotic and laparoscopic abdominoperineal resection. DESIGN This was a retrospective, case-matched patient cohort. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent either laparoscopic or robotic abdominoperineal resections between January 2008 and April 2017; they were case-matched in a 1:1 ratio based on age ±5 years, BMI ±3 kg/m 2 , and sex criteria. MAIN OUTCOME MEASURES Perioperative, oncologic, and economic (including survival) outcomes were compared. Because of institutional policy, actual cost values are presented as the lowest direct cost value as "100%," and other values are presented as proportional to the index value. RESULTS We examined 68 patients (34 in each group). Both groups had similar preoperative characteristics, including preoperative chemoradiation rates. Operative time (319 vs 309 min), length of stay (7.2 vs 7.4 d), postoperative complications (38.2% vs 41.2%), conversion to open (5 vs 4), complete mesorectal excision (76.4% vs 79.4%), radial margin involvement (2.9% vs 8.9%), and direct hospital cost parameters (mean difference 26%, median difference 43%) were comparable between robotic and laparoscopic abdominoperineal resection groups, respectively (all p > 0.05). Local recurrence, disease-free survival, and overall survival rates (85.3% vs 76.5%) were also similar after 22 months of follow-up between the groups. LIMITATIONS The main limitations of this study are its retrospective nature and the variety in concomitant procedures. CONCLUSIONS Robotic abdominoperineal resections provided in carefully matched patients with rectal cancer showed similar perioperative and short-term oncologic outcomes compared to laparoscopic abdominoperineal resections. Our study was not powered to detect a significant increase in cost with robotic abdominoperineal resections. See Video Abstract at http://links.lww.com/DCR/B920 . RESULTADOS Y ANLISIS DE COSTO DE LA RESECCIN ABDOMINOPERINEAL LAPAROSCPICA VS LA ROBTICA EN CASOS DE CNCER DE RECTO ESTUDIO DE CASOS EMPAREJADOS ANTECEDENTES:Si bien la resección abdominoperineal laparoscópica está bien definida, la literatura carece de estudios comparativos sobre la resección abdominoperineal robótica. Dado que las resecciones abdominoperineales robóticas generalmente no requieren movilización esplénica o una anastomosis en casos de reconstrucción, se supone que el tiempo medio en la consola sea más corto que durante una resección anterior baja. Hipotéticamente las resecciones abdominoperineales robóticas y laparoscópicas nos proporcionarían resultados oncológicos y económicos similares.OBJETIVO:Comparar los resultados perioperatorios, oncológicos y económicos de la resección abdominoperineal robótica y laparoscópica.DISEÑO:Esta fue una cohorte de pacientes retrospectiva, emparejada por casos.AJUSTE:Estudio realizado en un centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a resecciones abdominoperineales LAParoscópicas o ROBóticas entre Enero de 2008 y Abril de 2017 fueron identificados y emparejados según la edad ±5, el IMC ±3 y los criterios de sexo en una proporción de 1:1.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados perioperatorios, oncológicos y económicos (incluida la sobrevida). Debido a la política institucional, los valores de costos reales se presentan como el valor de costo directo más bajo al 100% y los otros valores se presentan como proporcionales al valor índice.RESULTADOS:Se analizaron 68 pacientes (LAP-34 y ROB-34). Ambos grupos tenían características preoperatorias similares, incluidas las tasas de radio-quimioterapia pre-operatoria. Los tiempos operatorios fueron de 319 y 309 minutos, la estadía hospitalaria de 7 días en los dos grupos, las complicaciones post-operatorias fueron de 38,2% LAP frente a 41,2% ROB, la tasa de conversion fué de 5 a 4, la excisión total del mesorrecto de 76,4% frente a 79,4%, la resección radial con afectación de los márgenes de 2,9% frente a 8,9% y los parámetros de costes hospitalarios directos (diferencia de medias 26%, diferencia de medianas 43%) fueron comparables entre los grupos, de resección abdominoperineal robótica y laparoscópica, respectivamente (todos p > 0,05). Las tasas de recurrencia local, sobrevida libre de enfermedad y sobrevida general (85,3% frente a 76,5%) también fueron similares después de 22 meses de seguimiento entre los grupos.LIMITACIONES:La naturaleza retrospectiva y la variedad de procedimientos concomitantes fueron las principales limitaciones de este estudio.CONCLUSIONES:Las resecciones abdominoperineales robóticas proporcionaron resultados oncológicos perioperatorios y a corto plazo similares en pacientes con cáncer de recto cuidadosamente emparejados en comparación con las resecciones abdominoperineales laparoscópicas. Nuestro estudio no fue diseñado para detectar un aumento significativo en el costo relacionado con la resección abdominoperineal robótica. Consulte Video Resumen en http://links.lww.com/DCR/B920 . (Traducción-Dr. Xavier Delgadillo ).
Collapse
|
|
18
|
Ali M, Zhu X, Wang Y, Ding J, Zhang Q, Sun Q, Baral S, Wang D. A retrospective study of post-operative complications and cost analysis in robotic rectal resection versus laparoscopic rectal resection. Front Surg 2022; 9:969038. [PMID: 36061066 PMCID: PMC9437576 DOI: 10.3389/fsurg.2022.969038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background Robotic rectal cancer surgery has proven to be a viable alternative to laparoscopic surgery in treating rectal cancer. This study assessed the short-term operative measures of robotic versus laparoscopic surgery. Material Data was obtained retrospectively from July 2019 to November 2021. Patient demographics, pre-and post-operative features, initial bowel movement, length of hospital stay, and short-term postoperative outcomes such as harvested lymph node, sepsis, Clavien–Dindo Classification, and cost were evaluated. Results A total of 155 patients were treated for colorectal cancer, with 64 receiving robotic surgery and 91 receiving laparoscopic surgery. According to the Clavien–Dindo classification, there is a significant P < 0.05 between robotic and laparoscopic rectal surgery, with robotic having fewer patients in grade III-IV than laparoscopic. Despite this, laparoscopic surgery is associated with more sepsis patients (P < 0.05), and harvested lymph nodes are likewise associated with significant results. Conclusion With respect to post-operative complication and cost analysis, our finding imply that robotic rectal resection achieves better-quality short-term outcome but more costly than laparoscopic as well as Clavien–Dindo classification plays a crucial role in assessing postoperative rectal cancer complications and considerably impacts the quality of life.
Collapse
Affiliation(s)
- Muhammad Ali
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Xiaodong Zhu
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Yang Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Jianyue Ding
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Qi Zhang
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Qiannan Sun
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Shantanu Baral
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Daorong Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Correspondence: Daorong Wang
| |
Collapse
|
|
19
|
Spinelli A. Colorectal Cancer: Minimally Invasive Surgery. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:619-642. [DOI: 10.1007/978-3-030-66049-9_36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
20
|
Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis. J Robot Surg 2021; 16:1233-1247. [PMID: 34972981 PMCID: PMC9606098 DOI: 10.1007/s11701-021-01361-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.
Collapse
|
|
21
|
Concepts and prospects of minimally invasive colorectal cancer surgery. Clin Radiol 2021; 76:889-895. [PMID: 34654544 DOI: 10.1016/j.crad.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/15/2021] [Indexed: 01/18/2023]
Abstract
It is important that clinical radiologists understand and appreciate the minimally invasive surgery (MIS) options available to surgeons. Operative technologies are constantly evolving, and accurate, informed interpretation of clinical imaging is essential for optimum surgical management. Concurrent advancements in both MIS and radiological staging have certainly improved treatment decisions and outcomes. This article outlines the history, current concepts, evolving techniques, and future prospects of MIS as it pertains to colorectal cancer surgery.
Collapse
|
|
22
|
Cui CL, Luo WY, Cosman BC, Eisenstein S, Simpson D, Ramamoorthy S, Murphy J, Lopez N. Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation. Ann Surg Oncol 2021; 29:1894-1907. [PMID: 34529175 PMCID: PMC8810473 DOI: 10.1245/s10434-021-10576-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 06/22/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer. METHODS In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective. RESULTS WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0-250,000. CONCLUSIONS Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.
Collapse
Affiliation(s)
- Christina Liu Cui
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - William Yu Luo
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Bard Clifford Cosman
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA.,Veterans Affairs San Diego Medical Center, San Diego, CA, USA
| | - Samuel Eisenstein
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA
| | - Daniel Simpson
- Department of Radiation Medicine and Applied Science, University of California, San Diego, La Jolla, CA, USA
| | - Sonia Ramamoorthy
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA
| | - James Murphy
- Department of Radiation Medicine and Applied Science, University of California, San Diego, La Jolla, CA, USA
| | - Nicole Lopez
- Department of Surgery, Division of Colon and Rectal Surgery, University of California, San Diego Health Systems, La Jolla, CA, 92093-0987, USA.
| |
Collapse
|
|
23
|
Gunnells D, Cannon J. Robotic Surgery in Crohn's Disease. Clin Colon Rectal Surg 2021; 34:286-291. [PMID: 34512197 DOI: 10.1055/s-0041-1729862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.
Collapse
Affiliation(s)
- Drew Gunnells
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| | - Jamie Cannon
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| |
Collapse
|
|
24
|
Zhang GQ, Sahyoun R, Stem M, Lo BD, Rajput A, Efron JE, Atallah C, Safar B. Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer. World J Surg 2021; 45:3686-3694. [PMID: 34495388 DOI: 10.1007/s00268-021-06278-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). METHODS This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. RESULTS Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). CONCLUSIONS No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.
Collapse
Affiliation(s)
- George Q Zhang
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Sahyoun
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian D Lo
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Colorectal Research Unit, Ravitch Colorectal Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
|
25
|
Kasai S, Kagawa H, Shiomi A, Hino H, Manabe S, Yamaoka Y, Kato S, Hanaoka M, Kinugasa Y. Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study. Surg Today 2021; 52:643-651. [PMID: 34417866 DOI: 10.1007/s00595-021-02359-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection. METHODS This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared. RESULTS We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8 days vs. 11 days, p < 0.01). The positive resection margin rates were comparable between the two groups. CONCLUSION Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.
Collapse
Affiliation(s)
- Shunsuke Kasai
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroyasu Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hitoshi Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Shoichi Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yusuke Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Shunichiro Kato
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Marie Hanaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Yusuke Kinugasa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.,Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| |
Collapse
|
|
26
|
Miller JA, Wang H, Chang DT, Pollom EL. Cost-Effectiveness and Quality-Adjusted Survival of Watch and Wait After Complete Response to Chemoradiotherapy for Rectal Cancer. J Natl Cancer Inst 2021; 112:792-801. [PMID: 31930400 DOI: 10.1093/jnci/djaa003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. There is interest in deescalating local therapy after a clinical complete response to CRT. We hypothesized that a watch-and-wait (WW) strategy offers comparable cancer-specific survival, superior quality-adjusted survival, and reduced cost compared with upfront TME. METHODS We developed a decision-analytic model to compare WW, low anterior resection, and abdominoperineal resection for patients achieving a clinical complete response to CRT. Rates of local regrowth, pelvic recurrence, and distant metastasis were derived from series comparing WW with TME after pathologic complete response. Lifetime incremental costs and quality-adjusted life-years (QALY) were calculated between strategies, and sensitivity analyses were performed to study model uncertainty. RESULTS The base case 5-year cancer-specific survival was 93.5% (95% confidence interval [CI] = 91.5% to 94.9%) on a WW program compared with 95.9% (95% CI = 93.6% to 97.4%) after upfront TME. WW was dominant relative to low anterior resection, with cost savings of $28 500 (95% CI = $22 200 to $39 000) and incremental QALY of 0.527 (95% CI = 0.138 to 1.125). WW was also dominant relative to abdominoperineal resection, with a cost savings of $32 100 (95% CI = $21 800 to $49 200) and incremental QALY of 0.601 (95% CI = 0.213 to 1.208). WW remained dominant in sensitivity analysis unless the rate of surgical salvage fell to 73.0%. CONCLUSIONS Using current multi-institutional recurrence estimates, we observed comparable cancer-specific survival, superior quality-adjusted survival, and decreased costs with WW compared with upfront TME. Upfront TME was preferred when surgical salvage rates were low.
Collapse
Affiliation(s)
- Jacob A Miller
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Hannah Wang
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| |
Collapse
|
|
27
|
Real-world comparison of curative open, laparoscopic and robotic resections for sigmoid and rectal cancer-single center experience. J Robot Surg 2021; 16:315-321. [PMID: 33871771 DOI: 10.1007/s11701-021-01239-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
There has been an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. Aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in the robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups, respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.
Collapse
|
|
28
|
Outcomes of robotic-assisted vs conventional laparoscopic surgery among patients undergoing resection for rectal cancer: an observational single hospital study of 300 cases. J Robot Surg 2021; 16:179-187. [PMID: 33743145 DOI: 10.1007/s11701-021-01227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
Robotic-assisted laparoscopic surgery attempts to facilitate rectal surgery in the narrow space of the pelvis. The aim of this study is to compare the outcomes of robotic versus laparoscopic surgery for rectal cancer. Monocentric retrospective study including 300 patients who underwent robotic (n = 178) or laparoscopic (n = 122) resection between Jan 2009 and Dec 2017 for high, mid and low rectal cancer. The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, except for sex and ASA status. There were no statistical differences between groups in the conversion rate to open surgery. Surgical morbidity and oncological quality did not differ in either group, except for the anastomosis leakage rate and the affected distal resection margin. There were no differences in overall survival rate between the laparoscopic and robotic group. Robotic surgery could provide some advantages over conventional laparoscopic surgery, such as three-dimensional views, articulated instruments, lower fatigue, lower conversion rate to open surgery, shorter hospital stays and lower urinary and sexual dysfunctions. On the other hand, robotic surgery usually implies longer operation times and higher costs. As shown in the ROLARR trial, no statistical differences in conversion rate were found between the groups in our study. When performed by experienced surgeons, robotic surgery for rectal cancer could be a safe and feasible option with no significant differences in terms of oncological outcomes in comparison to laparoscopic surgery.
Collapse
|
|
29
|
Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity. World J Surg 2021; 44:3130-3140. [PMID: 32383054 DOI: 10.1007/s00268-020-05560-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. METHODS Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. RESULTS A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. CONCLUSION Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.
Collapse
|
|
30
|
Moghadamyeghaneh Z, Talus H, Fitzgerald S, Muthusamy M, Stamos MJ, Roudnitsky V. Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis. Am Surg 2020; 87:561-567. [PMID: 33118383 DOI: 10.1177/0003134820950295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality. METHODS The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach. RESULTS We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0). CONCLUSION The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.
Collapse
Affiliation(s)
| | - Henry Talus
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Simon Fitzgerald
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Muthukumar Muthusamy
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, CA, USA
| | - Valery Roudnitsky
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| |
Collapse
|
|
31
|
Abstract
INTRODUCTION As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits. TECHNIQUE After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect. RESULTS After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap. CONCLUSIONS This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
Collapse
|
|
32
|
Ryan OK, Ryan ÉJ, Creavin B, Rausa E, Kelly ME, Petrelli F, Bonitta G, Kennelly R, Hanly A, Martin ST, Winter DC. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur J Surg Oncol 2020; 47:285-295. [PMID: 33280950 DOI: 10.1016/j.ejso.2020.06.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal approach for total mesorectal excision (TME) of rectal cancer remains controversial. AIM To compare short- and long-term outcomes after open (OpTME), laparoscopic (LapTME), robotic (RoTME) and transanal TME (TaTME). METHODS A systematic search of electronic databases was performed up to January 1, 2020 for randomized controlled trials (RCTs) comparing at least 2 TME strategies. A Bayesian arm-based random effect network meta-analysis (NMA) was performed, specifically, a mixed treatment comparison (MTC). RESULTS 30 RCTs (and six updates) of 5586 patients with rectal cancer were included. No significant differences were identified in recurrence rates or survival rates. Operating time was shorter with OpTME (surface under the cumulative ranking curve [SUCRA] 0.96) compared to LapTME, RoTME and TaTME. Although OpTME was associated with the most blood loss (SUCRA 0.90) and had a slower recovery with increased length of stay (SUCRA 0.90) compared to the minimally invasive techniques, there was no difference in postoperative morbidity. OpTME was associated with a more complete TME specimen compared to LapTME (Risk Ratio [RR] 1.05, 95% Credible Interval [CrI] 1.01, 1.11), and TaTME had less involved CRMs (RR 0.173, 95% CrI 0.02, 0.76) versus LapTME. There were no differences between the modalities in terms of deep TME defects, DRM distance, or lymph node yield. CONCLUSIONS While OpTME was the most effective TME modality for short term histopathological resection quality, there was no difference in long-term oncologic outcomes. Minimally invasive approaches enhance postoperative recovery, at the cost of longer operating times. Technique selection should be based on individual tumour characteristics and patient expectations, as well as surgeon and institutional expertise.
Collapse
Affiliation(s)
- Odhrán K Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Emanuele Rausa
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Michael E Kelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Fausto Petrelli
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Gianluca Bonitta
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Rory Kennelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Ann Hanly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| |
Collapse
|
|
33
|
Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation. Asian J Surg 2020; 44:199-205. [PMID: 32571714 DOI: 10.1016/j.asjsur.2020.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development. METHODS Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery. RESULTS The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively). CONCLUSIONS The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.
Collapse
|
|
34
|
Villano AM, Zeymo A, Houlihan BK, Bayasi M, Al-Refaie WB, Chan KS. Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes. J Surg Res 2020; 247:180-189. [DOI: 10.1016/j.jss.2019.07.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/24/2019] [Accepted: 07/07/2019] [Indexed: 02/07/2023]
|
|
35
|
Douissard J, Obias V, Johnson CS, Hagen ME, Keller D, Ouellette JR, Hellan M. Totally robotic vs hybrid abdominoperineal resection: A retrospective multicenter analysis. Int J Med Robot 2019; 16:e2073. [PMID: 31876089 DOI: 10.1002/rcs.2073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/15/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Laparoscopic abdominoperineal resection (APR) for low rectal cancers is technically demanding. Robotic assistance may be of help and can be hybrid (HAPR) or totally robotic (RAPR). The present study describes outcomes of robotic APR and compares both approaches. MATERIAL AND METHODS A multicentric retrospective analysis of rectal cancer patients undergoing either HAPR or RAPR was conducted. Patients' demographics, surgeons' experience, oncologic results, and intraoperative and postoperative outcomes were collected. RESULTS One hundred twenty-five patients were included, 48 in HAPR group and 77 in RAPR group. Demographics and comorbidities were comparable. Operative time was reduced in RAPR group (266.9 ± 107.8 min vs 318.9 ± 75.1 min, P = .001). RAPR patients were discharged home more frequently (91.18% vs 66.67%, P = .001), and experienced fewer parastomal hernias (3.71% vs 9.86%, P = .001). CONCLUSION RAPR is safe and feasible with appropriate oncologic outcomes. Totally robotic approach reduces operative time and may improve functional outcomes.
Collapse
Affiliation(s)
- Jonathan Douissard
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Vincent Obias
- Division of Colorectal Surgery, Department of Surgery, George Washington University Hospital, Washington, DC
| | | | - Monika E Hagen
- Visceral Surgery Department, Geneva University Hospital, Geneva, Switzerland
| | - Deborah Keller
- Division of Colorectal Surgery, Department of Surgery, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - James R Ouellette
- Surgical Oncology Division, Wright State University - Boonshoft School of Medicine, Centerville, Ohio
| | - Minia Hellan
- Wright State University - Boonshoft School of Medicine, Kettering Cancer Care, Kettering, Ohio
| |
Collapse
|
|
36
|
Lee GC, Bordeianou LG, Francone TD, Blaszkowsky LS, Goldstone RN, Ricciardi R, Kunitake H, Qadan M. Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection. Surg Endosc 2019; 34:3435-3448. [PMID: 31844971 DOI: 10.1007/s00464-019-07120-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 09/13/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer. METHODS We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010-2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion. RESULTS A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72-0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04-1.21), shorter length of stay (OR 0.57, 95% CI 0.53-0.62), and improved overall survival (HR 0.90, 95% CI 0.83-0.98). CONCLUSIONS MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.
Collapse
Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Liliana G Bordeianou
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Todd D Francone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Lawrence S Blaszkowsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Robert N Goldstone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
- Newton Wellesley Hospital, Newton, MA, 02462, USA.
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
- Newton Wellesley Hospital, Newton, MA, 02462, USA.
| |
Collapse
|
|
37
|
Hopkins MB, Geiger TM, Bethurum AJ, Ford MM, Muldoon RL, Beck DE, Stewart TG, Hawkins AT. Comparing pathologic outcomes for robotic versus laparoscopic Surgery in rectal cancer resection: a propensity adjusted analysis of 7616 patients. Surg Endosc 2019; 34:2613-2622. [PMID: 31346754 DOI: 10.1007/s00464-019-07032-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Margin negative resection of rectal cancer with minimally invasive techniques remains technically challenging. Robotic surgery has potential advantages over traditional laparoscopy. We hypothesize that the difference in the rate of negative margin status will be < 6% between laparoscopic and robotic approach. METHODS The National Cancer Database (2010-2014) was queried for adults with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and curative resection to conduct an observational retrospective cohort study of a prospectively maintained database. Patients were grouped by either robotic (ROB) or laparoscopic (LAP) approach in an intent-to-treat analysis. Primary outcome was negative margin status, defined as a composite of circumferential resection margin and distal margin. Secondary outcomes included length of stay (LOS), readmission, 90-day mortality, and overall survival. RESULTS 7616 patients with locally advanced rectal cancer who underwent minimally invasive resection were identified. 2472 (32%) underwent attempted robotic approach. The overall conversion rate was 13% and was increased in the laparoscopic group [LAP: 15% vs. ROB: 8%; OR 0.47; 95% CI (0.39, 0.57)]. Differences in margin negative resection rate were within the prespecified range of practical equivalence (LAP: 93% vs.: ROB 94%; 95% CI (0.69, 1.06); [Formula: see text] = 1). For secondary outcomes, there was no difference in 30-day readmission [LAP: 9% vs.: ROB 8%; 95% CI (0.84, 1.24)] and 90-day mortality [LAP: 1% vs.: ROB 1%; 95% CI (0.38, 1.24)]. While the median LOS was 5 days in both groups, the mean LOS was 0.6 (95% CI: 0.24, 0.89) days shorter in the robotic group. CONCLUSION This robust analysis supports either robotic or laparoscopic approach for resection of locally advanced rectal cancer from a margin perspective. Both have similar readmission and 5-year overall survival rates. Patients undergoing robotic surgery have a 0.6-day decrease in LOS and decreased conversion rate.
Collapse
Affiliation(s)
- M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Timothy M Geiger
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Alva J Bethurum
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Molly M Ford
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Roberta L Muldoon
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - David E Beck
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Vanderbilt University, 1161 21st Ave South, Room D5248 MCN, Nashville, TN, 37232, USA.
| |
Collapse
|
|
38
|
Alsowaina KN, Schlachta CM, Alkhamesi NA. Cost-effectiveness of current approaches in rectal surgery. Ann Med Surg (Lond) 2019; 45:36-39. [PMID: 31360458 PMCID: PMC6639648 DOI: 10.1016/j.amsu.2019.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer is ranked as the fourth malignant cause of mortality. With the tremendous revolution in the modern medical techniques, minimally invasive approaches have been incorporated into rectal surgery. The effectiveness of surgical procedures is usually measured by a combination of qualitative (quality of life) and quantitative (years of life) measures, while the costs should reflect the use of different resources that were involved in delivering the medical care and they are affected by several factors, including length of hospital stay. In this review, we provide an insight into the cost-effectiveness of the different types of rectal surgeries in order to present a systematic approach for future preferences. A comprehensive literature review using Medline (via PUBMED), Embase and Cochrane Central Register of clinical trials (via clinical trial.org) was performed. Minimally invasive rectal surgeries have considerable cost-effective properties that outweigh those of the open techniques in terms of earlier return to bowel function, lower morbidity rates, reduced pain, shorter length of hospital stay and the overall patients’ quality of life although there was no difference in long-term oncological and survival outcomes. The paucity of currently available long-term oncologic, quality of life, and economic outcomes may limit an adequate comparison of robotic surgeries to other surgical techniques. It is therefore recommended to conduct focused studies to help balance the cost/benefit factors along with other technical considerations aimed at reducing the cost of robotic systems with subsequent improvement of their cost-effectiveness.
Colorectal cancer is the fourth cause of mortality. Minimally invasive surgery is now considered the standard of care. Cost of minimally invasive surgery is offset by the better outcomes due to less complications and shorter hospital stay. TaTME requires two working teams and two sets of instruments which increases the total cost. Robotic surgery in obese patients demonstrated superior results when it comes to hospital stay and overall complications. Well conducted clinical trials looking at cost effectiveness of new technologies in colorectal surgery are needed.
Collapse
Affiliation(s)
- Khalid N Alsowaina
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| | - Christopher M Schlachta
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| | - Nawar A Alkhamesi
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), London Health Sciences Centre, Canada.,Department of Surgery, Western University, London, Ontario, Canada
| |
Collapse
|
|
39
|
Ng KT, Tsia AKV, Chong VYL. Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. World J Surg 2019; 43:1146-1161. [PMID: 30610272 DOI: 10.1007/s00268-018-04896-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally invasive surgery has been considered as an alternative to open surgery by surgeons for colorectal cancer. However, the efficacy and safety profiles of robotic and conventional laparoscopic surgery for colorectal cancer remain unclear in the literature. The primary aim of this review was to determine whether robotic-assisted laparoscopic surgery (RAS) has better clinical outcomes for colorectal cancer patients than conventional laparoscopic surgery (CLS). METHODS All randomized clinical trials (RCTs) and observational studies were systematically searched in the databases of CENTRAL, EMBASE and PubMed from their inception until January 2018. Case reports, case series and non-systematic reviews were excluded. RESULTS Seventy-three studies (6 RCTs and 67 observational studies) were eligible (n = 169,236) for inclusion in the data synthesis. In comparison with the CLS arm, RAS cohort was associated with a significant reduction in the incidence of conversion to open surgery (ρ < 0.001, I2 = 65%; REM: OR 0.40; 95% CI 0.30,0.53), all-cause mortality (ρ < 0.001, I2 = 7%; FEM: OR 0.48; 95% CI 0.36,0.64) and wound infection (ρ < 0.001, I2 = 0%; FEM: OR 1.24; 95% CI 1.11,1.39). Patients who received RAS had a significantly shorter duration of hospitalization (ρ < 0.001, I2 = 94%; REM: MD - 0.77; 95% CI 1.12, - 0.41; day), time to oral diet (ρ < 0.001, I2 = 60%; REM: MD - 0.43; 95% CI - 0.64, - 0.21; day) and lesser intraoperative blood loss (ρ = 0.01, I2 = 88%; REM: MD - 18.05; 95% CI - 32.24, - 3.85; ml). However, RAS cohort was noted to require a significant longer duration of operative time (ρ < 0.001, I2 = 93%; REM: MD 38.19; 95% CI 28.78,47.60; min). CONCLUSIONS This meta-analysis suggests that RAS provides better clinical outcomes for colorectal cancer patients as compared to the CLS at the expense of longer duration of operative time. However, the inconclusive trial sequential analysis and an overall low level of evidence in this review warrant future adequately powered RCTs to draw firm conclusion.
Collapse
Affiliation(s)
- Ka Ting Ng
- Faculty of Medicine, University of Malaya, Jalan Universiti, 50603, Kuala Lumpur, Malaysia.
| | - Azlan Kok Vui Tsia
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| | - Vanessa Yu Ling Chong
- Department of Surgery, International Medical University, Bukit Jalil, 50603, Kuala Lumpur, Malaysia
| |
Collapse
|
|
40
|
Osagiede O, Spaulding AC, Cochuyt JJ, Naessens J, Merchea A, Colibaseanu DT. Trends in the Use of Laparoscopy and Robotics for Colorectal Cancer in Florida. J Laparoendosc Adv Surg Tech A 2019; 29:926-933. [PMID: 31094645 DOI: 10.1089/lap.2019.0016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.
Collapse
Affiliation(s)
| | - Aaron C Spaulding
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Jordan J Cochuyt
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - James Naessens
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Amit Merchea
- 1 Department of Surgery and Mayo Clinic, Jacksonville, Florida
| | | |
Collapse
|
|
41
|
The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects. Int J Colorectal Dis 2019; 34:501-511. [PMID: 30610436 DOI: 10.1007/s00384-018-03222-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 02/04/2023]
Abstract
AIM Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. METHODS We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. RESULTS Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. CONCLUSIONS The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.
Collapse
|
|
42
|
Garfinkle R, Abou-Khalil M, Bhatnagar S, Wong-Chong N, Azoulay L, Morin N, Vasilevsky CA, Boutros M. A Comparison of Pathologic Outcomes of Open, Laparoscopic, and Robotic Resections for Rectal Cancer Using the ACS-NSQIP Proctectomy-Targeted Database: a Propensity Score Analysis. J Gastrointest Surg 2019; 23:348-356. [PMID: 30264386 DOI: 10.1007/s11605-018-3974-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/12/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is ongoing debate regarding the benefits of minimally invasive techniques for rectal cancer surgery. The aim of this study was to compare pathologic outcomes of patients who underwent rectal cancer resection by open surgery, laparoscopy, and robotic surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) proctectomy-targeted database. METHODS All patients from the 2016 ACS-NSQIP proctectomy-targeted database who underwent elective proctectomy for rectal cancer were identified. Patients were divided into three groups based on initial operative approach: open surgery, laparoscopy, and robotic surgery. Pathologic and 30-day clinical outcomes were then compared between the groups. A propensity score analysis was performed to control for confounders, and adjusted odds ratios for pathologic outcomes were reported. RESULTS A total of 578 patients were included-211 (36.5%) in the open group, 213 (36.9%) in the laparoscopic group, and 154 (26.6%) in the robotic group. Conversion to open surgery was more common among laparoscopic cases compared to robotic cases (15.0% vs. 6.5%, respectively; p = 0.011). Positive circumferential resection margin (CRM) was observed in 4.7%, 3.8%, and 5.2% (p = 0.79) of open, laparoscopic, and robotic resections, respectively. Propensity score adjusted odds ratios for positive CRM (open surgery as a reference group) were 0.70 (0.26-1.85, p = 0.47) for laparoscopy and 1.03 (0.39-2.70, p = 0.96) for robotic surgery. CONCLUSIONS The use of minimally invasive surgical techniques for rectal cancer surgery does not appear to confer worse pathologic outcomes.
Collapse
Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada
| | - Maria Abou-Khalil
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada
| | - Sahir Bhatnagar
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Nathalie Wong-Chong
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, G-317, Montreal, Quebec, H3T 1E2, Canada.
| |
Collapse
|
|
43
|
Oncological Outcomes After Robotic Proctectomy for Rectal Cancer: Analysis of a Prospective Database. Ann Surg 2019; 267:521-526. [PMID: 27997470 DOI: 10.1097/sla.0000000000002112] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the oncological outcomes of robotic total mesorectal excision (TME) at an NCI designated cancer center. SUMMARY BACKGROUND DATA The effectiveness of laparoscopic TME could not be established, but the robotic-assisted approach may hold some promise, with improved visualization and ergonomics for pelvic dissection. Oncological outcome data is presently lacking. METHODS Patients who underwent total mesorectal excision or tumor-specific mesorectal excision for rectal cancer between April 2009 and April 2016 via a robotic approach were identified from a prospective single-institution database. The circumferential resection margin (CRM), distal resection margin, and TME completeness rates were determined. Kaplan-Meier analysis of disease-free survival and overall survival was performed for all patients treated with curative intent. RESULTS A total of 276 patients underwent robotic proctectomy during the study period. Robotic surgery was performed initially by 1 surgeon with 3 additional surgeons progressively transitioning from open to robotic during the study period with annual increase in the total number of cases performed robotically. Seven patients had involved circumferential resection margins (2.5%), and there were no positive distal or proximal resection margins. One hundred eighty-six patients had TME quality assessed, and only 1 patient (0.5%) had an incomplete TME. Eighty-three patients were followed up for a minimum of 3 years, with a local recurrence rate of 2.4%, and a distant recurrence rate of 16.9%. Five-year disease-free survival on Kaplan-Meier analysis was 82%, and 5-year overall survival was 87%. CONCLUSIONS Robotic proctectomy for rectal cancer can be performed with good short and medium term oncological outcomes in selected patients.
Collapse
|
|
44
|
Patient Co-Morbidity and Functional Status Influence the Occurrence of Hospital Acquired Conditions More Strongly than Hospital Factors. J Gastrointest Surg 2019; 23:163-172. [PMID: 30225796 DOI: 10.1007/s11605-018-3957-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Never events (NE) and hospital-acquired conditions (HAC) are used by Medicare/Medicaid Services to define hospital performance measures that dictate payments/penalties. Pre-op patient comorbidity may significantly influence HAC development. METHODS We studied 8,118,615 patients from the NIS database (2002-2012) who underwent upper/lower gastrointestinal and/or hepatopancreatobiliary procedures. Multivariate analysis, using logistic regression, was used to identify HAC and NE risk factors. RESULTS A total of 63,762 (0.8%) HAC events and 1645 (0.02%) NE were reported. A total of 99.9% of NE were retained foreign body. Most frequent HAC were: pressure ulcer stage III/IV (36.7%), poor glycemic control (26.9%), vascular catheter-associated infection (20.3%), and catheter-associated urinary tract infection (13.7%). Factors correlating with HAC included: open surgical approach (AOR: 1.25, P < 0.01), high-risk patients with significant comorbidity [severe loss function pre-op (AOR: 6.65, P < 0.01), diabetes with complications (AOR: 2.40, P < 0.01), paraplegia (AOR: 3.14, P < 0.01), metastatic cancer (AOR: 1.30, P < 0.01), age > 70 (AOR: 1.09, P < 0.01)], hospital factors [small vs. large (AOR: 1.07, P < 0.01), non-teaching vs teaching (AOR: 1.10, P < 0.01), private profit vs. non-profit/governmental (AOR: 1.20, P < 0.01)], severe preoperative mortality risk (AOR: 3.48, P < 0.01), and non-elective admission (AOR: 1.38, P < 0.01). HAC were associated with increased: hospitalization length (21 vs 7 days, P < 0.01), hospital charges ($164,803 vs $54,858, P < 0.01), and mortality (8 vs 3%, AOR: 1.14, P < 0.01). CONCLUSION HAC incidence was highest among patients with severe comorbid conditions. While small, non-teaching, and for-profit hospitals had increased HAC, the strongest HAC risks were non-modifiable patient factors (preoperative loss function, diabetes, paraplegia, advanced age, etc.). This data questions the validity of using HAC as hospital performance measures, since hospitals caring for these complex patients would be unduly penalized. CMS should consider patient comorbidity as a crucial factor influencing HAC development.
Collapse
|
|
45
|
Osagiede O, Spaulding AC, Cochuyt JJ, Naessens JM, Merchea A, Kasi PM, Crandall M, Colibaseanu DT. Disparities in minimally invasive surgery for colorectal cancer in Florida. Am J Surg 2018; 218:293-301. [PMID: 30503514 DOI: 10.1016/j.amjsurg.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida. METHODS Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach. RESULTS Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001). CONCLUSIONS Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.
Collapse
Affiliation(s)
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Amit Merchea
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Pashtoon M Kasi
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Marie Crandall
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | | |
Collapse
|
|
46
|
Duchalais E, Machairas N, Kelley SR, Landmann RG, Merchea A, Colibaseanu DT, Mathis KL, Dozois EJ, Larson DW. Does obesity impact postoperative outcomes following robotic-assisted surgery for rectal cancer? Surg Endosc 2018; 32:4886-4892. [PMID: 29987562 DOI: 10.1007/s00464-018-6247-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 05/29/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Obesity has been identified as a risk factor for both conversion and severe postoperative morbidity in patients undergoing laparoscopic rectal resection. Robotic-assisted surgery (RAS) is proposed to overcome some of the technical limitations associated with laparoscopic surgery for rectal cancer. The aim of our study was to determine if obesity remains a risk factor for severe morbidity in patients undergoing robotic-assisted rectal resection. PATIENTS This study was a retrospective review of a prospective database. A total of 183 patients undergoing restorative RAS for rectal cancer between 2007 and 2016 were divided into 2 groups: control (BMI < 30 kg/m2; n = 125) and obese (BMI ≥ 30 kg/m2; n = 58). Clinicopathologic data, 30-day postoperative morbidity, and perioperative outcomes were compared between groups. The main outcome was severe postoperative morbidity defined as any complication graded Clavien-Dindo ≥ 3. RESULTS Control and obese groups had similar clinicopathologic characteristics. Severe complications were observed in 9 (7%) and 4 (7%) patients, respectively (p > 0.99). Obesity did not impact conversion, anastomotic leak rate, length of stay, or readmission but was significantly associated with increased postoperative morbidity (29 vs. 45%; p = 0.04) and especially more postoperative ileus (11 vs. 26%; p = 0.01). Obesity and male gender were the two independent risk factors for postoperative overall morbidity (OR 1.97; 95% CI 1.02-3.94; p = 0.04 and OR 2.23; 95% CI 1.10-4.76; p = 0.03, respectively). CONCLUSION Obesity did not impact severe morbidity or conversion rate following RAS for rectal cancer but remained a risk factor for overall morbidity and especially postoperative ileus.
Collapse
Affiliation(s)
- E Duchalais
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - N Machairas
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - R G Landmann
- Division of Colon & Rectal Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - A Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - D T Colibaseanu
- Division of Colon & Rectal Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - K L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - E J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
|
47
|
Kim JC, Lee JL, Kim CW. Comparative analysis of robot-assisted vs. open abdominoperineal resection in terms of operative and initial oncological outcomes. Ann Surg Treat Res 2018; 95:37-44. [PMID: 29963538 PMCID: PMC6024082 DOI: 10.4174/astr.2018.95.1.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/07/2017] [Accepted: 12/01/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose The present study aimed to objectively evaluate robot-assisted abdominoperineal resection (APR) in comparison with open APR, in terms of operative elements and initial oncological outcomes. Methods A total of 118 patients with lower rectal adenocarcinoma who had undergone curative APR were consecutively enrolled between June 2010 and June 2016, i.e., robot-assisted group (n = 40) and open group (n = 78). Results Transabdominal extralevator muscle excision was more frequently performed in the robot-assisted group than in the open group (68% vs. 42%, P = 0.012). In the robot-assisted group, the pain score at one day after surgery was less than in the open group, and the resumption of bowel function was earlier (P = 0.043 and P = 0.002, respectively). The occurrence of circumferential resection margin involvement (CRM+) was more than 5 times greater in the open group than in the robot-assisted group, presenting a marginal significance (P = 0.057). Although important postoperative morbidity did not generally differ between the 2 groups, voiding difficulty and male sexual dysfunction appeared to be encountered more frequently in the open group than in the robot-assisted group. Conclusion The robot-assisted APR facilitated transabdominal extralevator excision and bowel recovery and demonstrated a trend towards reduced CRM+.
Collapse
Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, Asan Medical Center, Institute of Innovative Cancer Research, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Department of Surgery, Asan Medical Center, Institute of Innovative Cancer Research, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Department of Surgery, Asan Medical Center, Institute of Innovative Cancer Research, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
|
48
|
Tooley JE, Sceats LA, Bohl DD, Read B, Kin C. Frequency and timing of short-term complications following abdominoperineal resection. J Surg Res 2018; 231:69-76. [PMID: 30278971 DOI: 10.1016/j.jss.2018.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/28/2018] [Accepted: 05/04/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have become more popular. The differences in short-term complications between open and laparoscopic APR are poorly characterized. METHODS We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to determine the frequency and timing of onset of 30-d postoperative complications after APR and identify differences between open and laparoscopic APR. RESULTS A total of 7681 patients undergoing laparoscopic or open APR between 2011 and 2015 were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). Laparoscopic APR was associated with a 14% lower total complication rate compared to open APR (36.0% versus 50.1%, P < 0.001). This was primarily driven by a decreased rate of transfusion (10.7% versus 24.9%, P < 0.001) and surgical site infection (15.5% versus 21.2%, P < 0.001). Laparoscopic APR had shorter length of stay and decreased reoperation rate but similar rates of readmission and death. Cardiopulmonary complications occurred earlier in the postoperative period after APR, whereas infectious complications occurred later. CONCLUSIONS Short-term complications following APR are common and occur more frequently in patients who undergo open APR. This, along with factors such as risk of positive pathologic margins, surgeon skill set, and patient characteristics, should contribute to the decision-making process when planning rectal cancer surgery.
Collapse
Affiliation(s)
- James E Tooley
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lindsay A Sceats
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel D Bohl
- Department of Orthopedic Surgery, Rush University School of Medicine, Chicago, Illinois
| | - Blake Read
- Department of Colon and Rectal Surgery, Mount Sinai School of Medicine, New York, New York
| | - Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, California.
| |
Collapse
|
|
49
|
Prete FP, Pezzolla A, Prete F, Testini M, Marzaioli R, Patriti A, Jimenez-Rodriguez RM, Gurrado A, Strippoli GFM. Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2018; 267:1034-1046. [PMID: 28984644 DOI: 10.1097/sla.0000000000002523] [Citation(s) in RCA: 228] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery. SUMMARY OF BACKGROUND DATA Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data. METHODS We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods. RESULTS Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes. CONCLUSION Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.
Collapse
Affiliation(s)
- Francesco Paolo Prete
- Department of Emergency and Organ Transplantation (DETO), University Medical School "A. Moro" of Bari, Bari, Italy
- MSc Surgical Science and Practice (Oxon)
| | - Angela Pezzolla
- Department of Emergency and Organ Transplantation (DETO), University Medical School "A. Moro" of Bari, Bari, Italy
| | - Fernando Prete
- University Medical School "A. Moro" of Bari, Bari, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology, University Medical School "A. Moro" of Bari, Bari, Italy
| | - Rinaldo Marzaioli
- Department of Emergency and Organ Transplantation (DETO), University Medical School "A. Moro" of Bari, Bari, Italy
| | - Alberto Patriti
- Division of General Surgery, "Ospedali Riuniti Marche Nord", Pesaro-Fano, Italy
| | | | - Angela Gurrado
- Department of Biomedical Sciences and Human Oncology, University Medical School "A. Moro" of Bari, Bari, Italy
| | - Giovanni F M Strippoli
- University Medical School "A. Moro" of Bari, Bari, Italy
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Diaverum Medical Scientific Office, Lund, Sweden
| |
Collapse
|
|
50
|
Al-Mazrou AM, Baser O, Kiran RP. Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection. J Gastrointest Surg 2018; 22:1043-1051. [PMID: 29404985 DOI: 10.1007/s11605-018-3699-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 01/18/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time. METHODS From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years. RESULTS Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402). CONCLUSION Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.
Collapse
Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA.
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
| |
Collapse
|