Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases The purpose of this systemic review was to examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system Five randomized clinical trials encompassing 598 patients were included in the final analysis Two of them were multicenter trials The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) −192 days; 95 % confidence interval (CI) −261–−123 days; P < 000001) and number of complications (relative risk (RR) 078; 95 % CI 066–094; P = 0007) compared with open surgery in the setting of ERAS programs No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs

Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials.

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the nationwide inpatient sample

Importance Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons. Objective To assess rates of complications for MIC compared with OC among surgeons. Design, Setting, and Participants We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches. Main Outcomes and Measures Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC. Results Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P Conclusions and Relevance Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

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Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative.

Utilization of laparoscopy (LAP) has been increasing in general surgery for years, and there is currently a rapid increase in the utilization of robotic-assisted surgeries (RAS). This study evaluates trends in the surgical approach utilized in some commonly performed surgeries, the proportion of each approach within the procedures, and the cost of these surgeries based on the surgical approach. This is a retrospective study using the Vizient database. The database was queried using ICD-9 codes for colectomy, cholecystectomy, inguinal and ventral hernia repairs, and bariatric surgeries, either open, LAP, or robotically performed. Utilization trends were evaluated between quarters, over a 7-year period, and direct cost was compared between approaches. IBM SPSS v.23.0.0 was used for data analysis, with α = 0.05. 857,468 patients underwent colectomy, cholecystectomy, inguinal and ventral hernia repairs, and bariatric procedures. A significant decrease in open-approach utilization was seen in colectomy (71.8–61.9%), cholecystectomy (35.7–27.1%), and bariatric surgeries (20.1–10.1%), whereas both LAP and RAS utilization increased (p < 0.001). Significant RAS increase was seen in all five procedures: colectomy (0.4–8.0%), cholecystectomy (0.2–1.8%), IHR (19.9–29.4%), VHR (0.2–2.9%), and bariatric (0.6–5.4%), compared to a decrease in LAP (p < 0.001). Surgery cost was significantly higher for open ($14,364), followed by RAS ($11,376) and LAP ($7945), p < 0.001. Robotic technology is commonly viewed as enabling open procedures to be converted to minimally invasive, a trend not observed in our study. Our trends analysis revealed significant RAS utilization increase from LAP procedures and not from open procedure conversion, although specific surgeon data were not available. RAS were costlier than LAP for all five procedures. The benefits of rapid robot adoption and the forces that are driving these must be examined against a backdrop of burdening an already expensive healthcare system.

Growth in robotic-assisted procedures is from conversion of laparoscopic procedures and not from open surgeons’ conversion: a study of trends and costs

Limited data are available for the epidemiology and outcome of colorectal cancer in relation to the three main surgical treatment modalities (open, laparoscopic and robotic). Using the US National Inpatient Sample database from 2004 to 2012, we identified 1,265,684 hospitalized colorectal cancer patients. Over the 9 year period, there was a 13.5% decrease in the number of hospital admissions and a 43.5% decrease in in-hospital mortality. Comparing the trend of surgical modalities, there was a 35.4% decrease in open surgeries, a 3.5 fold increase in laparoscopic surgeries, and a 41.3 fold increase in robotic surgeries. Nonetheless, in 2012, open surgery still remained the preferred surgical treatment modality (65.4%), followed by laparoscopic (31.2%) and robotic surgeries (3.4%). Laparoscopic and robotic surgeries were associated with lower in-hospital mortality, fewer complications, and shorter length of stays, which might be explained by the elective nature of surgery and earlier tumor grades. After excluding patients with advanced tumor grades, laparoscopic surgery was still associated with better outcomes and lower costs than open surgery. On the contrary, robotic surgery was associated with the highest costs, without substantial outcome benefits over laparoscopic surgery. More studies are required to clarify the cost-effectiveness of robotic surgery.

Trends and Outcomes of Surgical Treatment for Colorectal Cancer between 2004 and 2012- an Analysis using National Inpatient Database.

Background Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. Objective We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak following low anterior resection. Design We performed a 1:1 randomized, controlled, parallel study. Recruitment of 450-1000 patients was planned over 2-years. Setting Multicenter. Patients Patients undergoing resection defined as anastomosis within 10cm of anal verge. Intervention Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. Main outcome measure Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. Results This study was concluded early due to decreasing accrual rates. A total of 25 centers recruited 347 patients, of which 178 were randomized to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p>0.05). Mean level of anastomosis was 5.2+3.1cm in perfusion compared to 5.2+3.3cm in standard (p>0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of PFN and 4.2% of standard (p=0.75). Anastomotic leak was reported in 9.0% of perfusion compared to 9.6% of standard (p=0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR 0.845; 95% CI (0.375, 1.905); p=0.34). Limitations The pre-determined sample size to adequately reduce the risk of type II error was not achieved. Conclusion Successful visualization of perfusion can be achieved with ICG-F. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine ICG-F to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560 .

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

Objective:The study was designed to determine the growth pattern and current rate of laparoscopic partial colectomy in the United States and analyze various factors that influence the adaptation rate over time.Background:Laparoscopic colectomy has been shown to have significant short- and long-term

Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time.

The mastery of the field of colorectal surgery, with its multitude of complex procedures and ever evolving modalities, begins in general surgery residency, often progresses to fellowship, and continues throughout one’s career as a lifelong endeavor. Many learning curves are encountered and overcome at each stage. During the training phase the mastery of new skills is developed in a controlled environment monitored by experienced surgeons. Post-training the surgeon learns, develops, and masters new skills in an environment that is sometimes without a roadmap, yet he or she has to begin successfully implementing this skill in a safe manner for his/her patients. Although learning curves are inevitable, they also impact the subset of patients who fall under the front end of the surgeon’s learning curve. During the initial learning curve, many factors contribute to the surgeon’s eventual acquisition of the desired skill.

The Learning Curve of Robotic Assisted Laparoscopic Colorectal Surgery and How to Start Applying Robotic Technology in Colorectal Surgery

The purpose of this chapter is to review the technique of performing a laparoscopic sigmoid resection and left hemicolectomy. The essential steps of the procedure will be discussed in detail, including patient positioning, port placement, identification of key structures (inferior mesenteric artery pedicle, tumor, and ureter), mobilization techniques, extraction sites, and methods of reconstruction. While there are many different approaches to performing a sigmoid resection or Hartmann’s reversal, this chapter will describe the pure laparoscopic approach. Additionally, specific considerations and challenges encountered while performing a sigmoid resection will be reviewed.

Sigmoid Colectomy and Left Hemicolectomy: Laparoscopic Approach

Single-port laparoscopic approaches to colorectal procedures have been extensively reported for partial colectomies. Using a diverting or end ileostomy site might be especially useful for a proctocolectomy avoiding an additional extraction site with subsequent complications. We will review the single-port laparoscopic technique for a total colectomy and proctocolectomy.

Ovunc Bardakcioglu

Papers

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

Growth of laparoscopic colectomy in the United States: analysis of regional and socioeconomic factors over time.

The Learning Curve of Robotic Assisted Laparoscopic Colorectal Surgery and How to Start Applying Robotic Technology in Colorectal Surgery

Sigmoid Colectomy and Left Hemicolectomy: Laparoscopic Approach

Total Colectomy and Proctocolectomy: Single-Port Laparoscopic Approach