Short-Stay Left Colectomy for Colon Cancer: Is It Safe?

BACKGROUND: Advances in surgical practices have decreased hospital length of stay (LOS) after surgery. This study aimed to determine the safety of short-stay (≤24-hour) left colectomy for colon cancer patients in the US. STUDY DESIGN: Adult colon cancer patients who underwent elective left colectomies were identified using the American College of Surgeons NSQIP database (2012 to 2021). Patients were categorized into 4 LOS groups: LOS 1 day or less (≤24-hour short stay), 2 to 4, 5 to 6, and 7 or more. Primary outcomes were 30-day postoperative overall and serious morbidity. Secondary outcomes were 30-day mortality and readmission. Multivariable logistic regression was performed to explore the association between LOS and overall and serious morbidity. RESULTS: A total of 15,745 patients who underwent left colectomies for colon cancer were identified with 294 (1.87%) patients undergoing short stay. Short-stay patients were generally younger and healthier with lower 30-day overall morbidity rates (LOS ≤1 day: 3.74%, 2 to 4: 7.38%, 5 to 6: 16.12%, and ≥7: 37.64%, p < 0.001). Compared with patients with LOS 2 to 4 days, no differences in mortality and readmission rates were observed. On adjusted analysis, there was no statistical difference in the odds of overall (LOS 2 to 4 days: odds ratio 1.90, 95% CI 1.01 to 3.60, p = 0.049) and serious morbidity (LOS 2 to 4 days: odds ratio 0.86, 95% CI 1.42 to 1.76, p = 0.672) between the short-stay and LOS 2 to 4 days groups. CONCLUSIONS: Although currently performed at low rates in the US, short-stay left colectomy is safe for a select group of patients. Attention to patient selection, refinement of clinical pathways, and close follow-up may enable short-stay colectomies to become a more feasible reality.

National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease.

BACKGROUND: Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD. METHODS: Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed. RESULTS: The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results. CONCLUSION: The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery.

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal.

PURPOSE: Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. METHODS: From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m2, (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. RESULTS: 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). CONCLUSION: A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Disparities in utilization of robotic surgery for colon cancer: an evaluation of the U.S. National Cancer Database.

Despite the benefits of minimally invasive surgery for colorectal procedures, significant disparities in access to these techniques remain. While these gaps have been well-documented for laparoscopy, few studies have evaluated inequalities in access to robotic surgery. We analyze whether disparities exist in the use of robotic surgery in the management of colon cancer. The U.S. National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma who underwent resection with the robotic platform (2010-2016). Demographic, clinicopathologic, and treatment facility-related variables were analyzed with respect to preferential utilization of robotic surgery with multivariable logistic regression. Patients with metastatic disease, missing or incomplete surgical information, and those who underwent local tumor excision were excluded. 74,984 patients were identified, 3001 (4%) of whom underwent robotic surgery. In multivariable analysis, patients who were older, Black, or were living in an urban area had decreased odds of receiving robotic surgery compared with open or laparoscopic surgery. Patients who were privately insured or living in areas with higher education had increased odds of receiving robotic surgery. Robotic surgery was also preferentially associated with lower clinical stage, more recent year of diagnosis, and hospitals with higher procedural volume. As advantages of the robotic platform are becoming better understood, use of this approach is increasing in popularity for treatment of non-metastatic colon cancer. Despite this, significant disparities exist with respect to patient demographics and socioeconomic factors, and access may only be limited to certain types of hospitals. Further studies are needed to define why these inequalities exist.

The impact of surgical approach on short- and long-term outcomes after rectal cancer resection in elderly patients: a national cancer database propensity score matched comparison of robotic, laparoscopic, and open approaches.

BACKGROUND: Elderly patients are underrepresented in studies demonstrating the advantages of laparoscopy for the management of colorectal diseases. Moreover, few studies have examined the robotic approach in this population. In this retrospective analysis, we compare outcomes for open, laparoscopic, and robotic approaches in elderly patients with nonmetastatic rectal cancer. METHODS: The U.S. National Cancer Database was queried for patients aged ≥ 65 with nonmetastatic adenocarcinoma of the rectum who underwent surgical resection from 2010 to 2016. Groups were separated based on approach (open, laparoscopic, robotic). One-to-one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze the primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. RESULTS: Inclusion criteria and PSM identified 1891 patients per approach (n = 5673). PSM provided adequate discrimination between cohorts (0.6 < AUC < 0.8), and potential confounding covariates did not significantly differ (respective P > 0.05). After PSM, robotic and laparoscopic approaches were associated with decreased odds of 90 day mortality compared to the open approach (P < 0.05). Compared to laparoscopy, a robotic approach was associated with increased odds of ≥ 12 regional lymph nodes examined and negative circumferential resection margin (P < 0.05). No differences were seen in 30 day or 90 day mortality between robotic and laparoscopic approaches. Cox proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. CONCLUSION: Our study demonstrates that in elderly patients, minimally invasive surgery for rectal adenocarcinoma was associated with equivalent or improved short- and long-term mortality over open surgery. Compared to laparoscopy, the robotic approach showed no survival disadvantage and greater odds of an appropriate oncological resection. Our study adds evidence to the conclusion that robotic rectal surgery can be safely performed in patients regardless of age.

Open versus minimally invasive small bowel resection for Crohn's disease: a NSQIP retrospective review and analysis.

INTRODUCTION: Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database. METHODS: The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. RESULTS: After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery. CONCLUSIONS: This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease.

Short-term outcomes following resection of right colon diverticulitis: a comparison of open and minimally invasive approaches using the NSQIP database.

BACKGROUND: Right colon diverticulitis is a rare disease process for which there are no established treatment guidelines, and outcomes following surgical management are underreported in the literature. We sought to describe the demographics of patients undergoing ileocecectomy for right colon diverticulitis and compare short-term postoperative outcomes between open and minimally invasive approaches. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried for patients with diverticulitis of the colon who underwent ileocecectomy between 2012 and 2019. Patients with ascites, disseminated cancer, ASA class 5, and patients requiring mechanical ventilation were excluded. Preoperative, intraoperative, and 30-day postoperative outcomes were compared between the groups using both univariable chi-square or t-tests and multivariable logistical regression models. RESULTS: 484 patients met inclusion criteria, 150 (31%) of whom underwent open surgery and 334 (69%) who underwent minimally invasive surgery with an 18% conversion rate. 71% of patients were White, 11% of were Black, 7% were Hispanic, and 5% were Asian. The indication for surgery differed significantly by approach with acute diverticulitis representing 47% of indications for open cases and 25% for MIS cases (p < 0.0001). After adjusting for possible confounders, patients undergoing the open approach had a significantly higher chance of post-operative sepsis (p = 0.009) and ileus (p = 0.04) compared with MIS. Hospital length of stay was also significantly shorter after MIS compared to open (5.9 days vs. 11.5 days; p < 0.0001). Mean operative time was significantly longer in MIS than open (173 min vs. 198 min; p = 0.001). CONCLUSION: Our analysis demonstrates that minimally invasive surgery is associated with equivalent or improved short-term morbidity and shorter hospital stay despite longer mean operative time. Interestingly, unlike other countries where the prevalence of right colon diverticulitis is higher, a minority of patients requiring operative therapy in our study of patients in the Western hemisphere were of Asian descent.

Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial.

BACKGROUND: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. METHODS: Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. RESULTS: There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups. CONCLUSION: In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.

Surgical management of splenic flexure colon cancer: a retrospective propensity-matched study comparing open and minimally invasive approaches using the national cancer database.

PURPOSE: Minimally invasive resection of colon cancer at the splenic flexure can be technically challenging with concerns for a suboptimal oncologic outcome. We aimed to compare open and minimally invasive approaches following curative resection. METHODS: The National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma at the splenic flexure who underwent resection from 2010 to 2016. Cohorts were separated into open and minimally invasive approaches, and demographic and clinicopathologic variables were compared. Propensity-score matching (PSM) was utilized to balance potential confounding covariates between cohorts to elucidate the independent association between surgical approach and outcomes. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival. Secondary outcomes were analyzed by way of logistic regression or Mann-Whitney U test. RESULTS: After matching, 842 patients were compared between approaches. Patients who underwent minimally invasive surgery had no significant difference in regional nodes ≥ 12 examined, positive margins, negative circumferential margins, unplanned 30-day readmission, or time from surgery to initiation of chemotherapy when compared to patients who underwent open surgery. Minimally invasive surgery was significantly associated with decreased odds of 30-day mortality, 90-day mortality, and decreased mortality hazard for 5-year overall survival compared to open surgery. CONCLUSION: The optimal approach for surgical management of splenic flexure colon cancer has not been standardized given its rarity and exclusion from randomized controlled trials. Our retrospective review suggests that minimally invasive resection of splenic flexure colon cancers in carefully selected patients is associated with equivalent oncologic outcomes as well as improved short and long-term survival compared to an open approach.

Mice with dysfunctional TGF-ß signaling develop altered intestinal microbiome and colorectal cancer resistant to 5FU.

Emerging data show a rise in colorectal cancer (CRC) incidence in young men and women that is often chemoresistant. One potential risk factor is an alteration in the microbiome. Here, we investigated the role of TGF-ß signaling on the intestinal microbiome and the efficacy of chemotherapy for CRC induced by azoxymethane and dextran sodium sulfate in mice. We used two genotypes of TGF-ß-signaling-deficient mice (Smad4+/- and Smad4+/-Sptbn1+/-), which developed CRC with similar phenotypes and had similar alterations in the intestinal microbiome. Using these mice, we evaluated the intestinal microbiome and determined the effect of dysfunctional TGF-ß signaling on the response to the chemotherapeutic agent 5-Fluoro-uracil (5FU) after induction of CRC. Using shotgun metagenomic sequencing, we determined gut microbiota composition in mice with CRC and found reduced amounts of beneficial species of Bacteroides and Parabacteroides in the mutants compared to the wild-type (WT) mice. Furthermore, the mutant mice with CRC were resistant to 5FU. Whereas the abundances of E. boltae, B.dorei, Lachnoclostridium sp., and Mordavella sp. were significantly reduced in mice with CRC, these species only recovered to basal amounts after 5FU treatment in WT mice, suggesting that the alterations in the intestinal microbiome resulting from compromised TGF-ß signaling impaired the response to 5FU. These findings could have implications for inhibiting the TGF-ß pathway in the treatment of CRC or other cancers.

Comparing outcomes for non-metastatic rectal cancer in academic vs. community centers: A propensity-matched analysis of the National Cancer Database.

BACKGROUND: Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions. METHODS: The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression. RESULTS: After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen. CONCLUSIONS: No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.

Robotic-assisted surgery for complicated and uncomplicated diverticulitis: A single-surgeon case-series comparison.

BACKGROUND: Robotic-assisted techniques in colorectal surgery have dramatically increased. Comparative data on the management of uncomplicated and complicated diverticulitis using robotics is lacking. The purpose of this study is to examine outcomes of patients who underwent robotic-assisted resection in diverticulitis. METHODS: A prospectively maintained database performed by a single surgeon was retrospectively reviewed to identify patients who underwent robotic-assisted surgery (RAS) for diverticulitis from October 2009 to November 2018. Demographic data, preoperative and intraoperative parameters and postoperative outcomes were assessed using χ2 or Fisher exact test with p values <0.05 considered significant. IRB approval was obtained for this study, #NCR190935. RESULTS: Comparison revealed significant differences in operative times (222 vs. 291 min, p < 0.00001), mean estimated blood loss (130 vs. 304 cc, p = 0.0003) and mean length of stay (3.9 vs. 5.0 days, p = 0.006). Low rates of postoperative complications were observed, with no significant differences noted for conversion to laparoscopy, surgical site infection, leak, intra-abdominal abscess, 30-day unplanned readmission or recurrence. CONCLUSION: Patients with complicated diverticulitis required longer operative time, had increased estimated blood loss and more often converted to an open procedure; however, overall rates of post-operative complications were low in both groups. RAS shows promise for use in complicated diverticulitis.

The impact of the AirSeal® valve-less trocar system in robotic colorectal surgery: a single-surgeon retrospective review.

BACKGROUND: Traditional trocar systems suffer from several innate flaws due to their silicone seal design. The AirSeal® is a valve-less trocar system that overcomes these flaws by utilizing a system of laminar flow and CO2 recirculation. The purpose of this paper is to examine the effect of the AirSeal® versus a traditional trocar system in operative time, EBL and post-operative complications. To the best of our knowledge, this is the first analysis of this system in robotic colorectal surgery. METHODS: A single surgeon's database was reviewed and all LAR and right hemicolectomy robotic cases from 2014-2015 and 2017-2018 were included for analysis. Patient demographic information was evaluated and primary outcomes examined were operative time, EBL, post-operative complications and hospital LOS. RESULTS: Ninety four patients were identified in the LAR cohort and 56 patients were identified in the right hemicolectomy cohort. Mean operative time for LAR was 293 ± 91.6 min in 2014-2015 and 232 ± 74.6 min in 2017-2018 (p = 0.001); however, this significant difference was not seen between right hemicolectomies. Mean EBL for LAR was 209 ± 189 cc in 2014-2015 and 150 ± 173.9 cc in 2017-2018 (p = 0.05); again, this significant difference was not appreciated for right hemicolectomies. There was no statistically significant difference in rates of wound infections, pneumonia, post-operative pneumonia, DVT/PE, intra-abdominal/pelvic abscesses, or unplanned 30-day readmission rate between 2014-2015 and 2017-2018. Length of stay was reduced in both populations between 2014-2015 and 2017-2018; however, it neither reached statistical significance. CONCLUSION: In patients undergoing low anterior resections, the AirSeal® trocar system demonstrated a statistically significant reduction in mean operative time and EBL compared to the traditional trocar system. There was also a trend towards decreased length of stay and post-operative complications with AirSeal® use in low anterior resections and right hemicolectomies. In patients undergoing distal colorectal procedures, the AirSeal® trocar system should be considered.

The robotic colorectal experience: an outcomes and learning curve analysis of 502 patients.

AIM: This study aimed to present our experience with robotic colorectal surgery since its establishment at our institution in 2009. By examining the outcomes of over 500 patients, our experience provides a basis for assessing the introduction of a robotic platform in a colorectal practice. Specific measures investigated include intraoperative data and postoperative outcomes for all operations using the robotic platform. In addition, for our most commonly performed operations we wished to analyse the learning curve to improve operative proficiency. This is the largest single-surgeon robotic database analysed to date. METHOD: A prospectively maintained database of patients who underwent robotic colorectal surgery by a single surgeon at the George Washington University Hospital was retrospectively reviewed. Demographic data and perioperative outcomes were assessed. Additionally, an operating time learning curve analysis was performed. RESULTS: Inclusion criteria identified 502 patients who underwent robotic colorectal surgery between October 2009 and December 2018. The most common indications for surgery were diverticulitis (22.9%), colon adenocarcinoma (22.1%) and rectal adenocarcinoma (19.5%). The most common operations were anterior/low anterior resection (33.9%), right hemicolectomy/ileocaecectomy (24.9%) and left hemicolectomy/sigmoidectomy (21.9%). The rate of conversion to open surgery was 4.8%. The most common postoperative complications were wound infection (5.0%), anastomotic leakage (4.0%) and abscess formation (2.8%). The operating time learning curve plateaued at 55-65 cases for anterior and low anterior resection and 35-45 cases for left hemicolectomy and sigmoidectomy. A clear learning curve was not seen in right hemicolectomy. CONCLUSION: Robotic-assisted surgery can be performed in a diverse colorectal practice with low rates of conversion and postoperative complications. Plateau performance was achieved after 65 anterior/low anterior resections and 45 left and sigmoid colectomies.

Trends in utilization, conversion rates, and outcomes for minimally invasive approaches to non-metastatic rectal cancer: a national cancer database analysis.

BACKGROUND: This study examined utilization and conversion rates for robotic and laparoscopic approaches to non-metastatic rectal cancer. Secondary aims were to examine short- and long-term outcomes of patients who underwent conversion to laparotomy from each approach. METHODS: The National Cancer Database (NCDB) was reviewed for all cases of non-metastatic adenocarcinoma of the rectum or rectosigmoid junction who underwent surgical resection from 2010 to 2016. Utilization rates of robotic, laparoscopic, and open approaches were examined. Patients were split into cohorts by approach. Subgroup analyses were performed by primary tumor site and surgical procedure. Multivariable analysis was performed by multivariable logistic regression for binary outcomes and multivariable general linear models for continuous outcomes. Survival analysis was performed by Kaplan-Meier and multivariable cox-proportional hazards regression. RESULTS: From 2010 to 2016, there was a statistically significant increase in utilization of the robotic and laparoscopic approaches over the study period and a statistically significant decrease in utilization of the open approach. The conversion rates for robotic and laparoscopic cohorts were 7.0% and 15.7%, p < 0.0001. Subgroup analysis revealed statistically lower conversion rates between robotic and laparoscopic approaches for rectosigmoid and rectal tumors and for LAR and APR. Converted cohorts had statistically significant higher odds of short term mortality than the non-converted cohorts (p < 0.05).Laparoscopic conversion had statistically higher odds of positive margins (p < 0.0001) and 30-day unplanned readmission (p < 0.0001) than the laparoscopic non-conversion. Increased adjusted mortality hazard was seen for converted laparoscopy relative to non-converted laparoscopy (p = 0.0019). CONCLUSION: From 2010 to 2016, there was a significant increase in utilization of minimally invasive approaches to surgical management of non-metastatic rectal cancer. A robotic approach demonstrated decreased conversion rates than a laparoscopic approach at the rectosigmoid junction and rectum and for LAR and APR. Improved outcomes were seen in the minimally invasive cohorts compared to those that converted to laparotomy.

Surgical resection of T4 colon cancers: an NCDB propensity score-matched analysis of open, laparoscopic, and robotic approaches.

Historically, T4 tumors of the colon have been a contraindication to minimally invasive resection. The purpose of this study was to conduct a National Cancer Database analysis to compare the outcomes after curative treatment for T4 colon cancer between robotic, laparoscopic, and open approaches. The US National Cancer Database was queried for patients with T4 adenocarcinoma of the colon who underwent curative resection. Groups were separated based on approach (open, laparoscopic, robotic). One to one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. Inclusion criteria and PSM identified 876 cases per treatment approach (n = 2628). PSM provided adequate discrimination between treatment cohorts (0.6 < AUC < 0.8) and potential confounding covariates did not significantly differ between cohorts (all respective P > 0.05). Patients who underwent a robotic approach had lower odds of conversion to laparotomy compared to the laparoscopic cohort (P < 0.0001). Laparoscopic and robotic approaches were associated with increased odds of > 12 lymph nodes examined, decreased odds of positive margins, and decreased odds of 30-day readmission, 30-day mortality, and 90-day mortality compared to the open approach. Cox-proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. Both laparoscopic and robotic-assisted surgeries achieved improved oncologic outcomes and survival compared to open resection of T4 cancers. A robotic-assisted approach was significantly associated with a lower conversion rate compared to the laparoscopic approach. This case-matched study demonstrates safety of using minimally invasive techniques in T4 cancers.

Robotic and laparoscopic surgical techniques in patients with Crohn's disease.

BACKGROUND: Crohn's disease has historically been managed medically with sparing use of surgical resection. With the development of strictures or fistulas, surgical management such as an ileocecal resection may become necessary. Minimally invasive options such as laparoscopic and robotic-assisted techniques are alternatives to open surgery. The purpose of this study was to evaluate the safety of minimally invasive surgery for Crohn's disease. METHODS: We performed a retrospective review of the National Surgical Quality Improvement Program (NSQIP) database to select 5158 patients with Crohn's disease who underwent ileocecal resection (open, laparoscopic, or robotic-assisted). Preoperative, perioperative, and 30-day postoperative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. RESULTS: The three treatment groups (open, laparoscopic, and robotic-assisted ileocecal resection) had 30-day postoperative outcomes reported in NSQIP. The average BMI was 25 kg/m2 and the average age was 41. The rate of anastomotic leaks was significantly higher in the open surgery group compared to the minimally invasive groups (p = 0.001). The open surgery group had a significantly higher reoperation rate (p = 0.0002) and wound infection rate (p < 0.0001). The robotic-assisted group had significantly longer operative times compared to the laparoscopic and open groups (p < 0.0001). CONCLUSIONS: The decision to operate on a patient with Crohn's disease involves selecting an approach based on patient factors, surgeon preference, and availability of equipment. When evaluating the short-term postoperative outcomes in patients that have undergone ileocecal resection for management of Crohn's, minimally invasive techniques have had a lower incidence of wound infections, anastomotic leaks, and re-intervention in carefully selected patients. This retrospective review of a large national database demonstrates the efficacy of minimally invasive techniques in managing Crohn's disease in selected patients.

Evaluation of Minimally Invasive Surgical Therapies for Ulcerative Colitis.

INTRODUCTION: Ulcerative colitis (UC) is a chronic inflammatory intestinal disorder that can be managed surgically with a proctocolectomy. Minimally invasive techniques such as laparoscopic or robotic-assisted surgery are available based on the surgeon's preference and familiarity. To date, there is a paucity of literature evaluating the safety of these techniques in comparison to the open approach in patients with UC. METHODS: We surveyed the National Surgical Quality Improvement Program (NSQIP) database to select patients with the diagnosis of UC who underwent either robotic, laparoscopic, or open proctocolectomy between 2012 and 2017. A total of 2129 patients were included in the study. The 30-day postoperative outcomes were compared using multivariable logistic regression models after adjusting for confounding variables. The confounding variables were defined as any preoperative variable that was associated with the type of procedure. RESULTS: The 30-day postoperative outcomes reported in the NSQIP database were reviewed for each of the treatment groups (open, laparoscopic, and robotic). The anastomotic leak rate was significantly higher in the open group (P = .022). The robotic and laparoscopic groups had significantly fewer occurrences of postoperative ileus (P = .0006) and wound infections (P < .0001). There were significantly more strokes, cardiac events, and pulmonary events in the open surgical group. Operative time was significantly shorter in the open group (P < .0001). Reintervention rates were not significantly different among the groups. CONCLUSIONS: Minimally invasive proctocolectomy has significantly fewer postoperative complications compared with open proctocolectomy for UC. There is no significant difference in the postoperative outcomes between robotic-assisted and laparoscopic proctocolectomy.