Supervised training of laparoscopic colorectal cancer resections does not adversely affect short- and long-term outcomes: a Propensity-score-matched cohort study.

BACKGROUND: Supervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself. METHODS: A prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes. RESULTS: From 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4-82.2) versus 81.9% (74.2-90.4) and 70.0% (60.8-80.6) versus 73.6% (64.9-83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32-1.02, p = 0.057) and 0.87 (0.51-1.48, p = 0.61), respectively (univariate Cox proportional hazard model). CONCLUSIONS: Standardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.

Postoperative morbidity of complete mesocolic excision and central vascular ligation in right colectomy: a retrospective comparative cohort study.

BACKGROUND: To investigate morbidity and mortality following complete mesocolic excision (CME) and central vascular ligation (CVL) in patients undergoing right colectomy. METHODS: Data from consecutive patients undergoing elective right colectomy at a university-affiliated referral centre were retrospectively analysed. Patients who underwent conventional right-sided colonic cancer surgery (January 2001-April 2009, n = 84) were compared to patients who underwent CME/CVL (May 2009-January 2015, n = 71). The primary end point was anastomotic leak. Secondary end points were delayed gastric emptying, severe respiratory failure, mortality and length of hospital stay. RESULTS: No significant difference was found in the rate of anastomotic leak (1.2% in the conventional versus 5.6% in the CME/CVL group, p = 0.108). Patients in the CME/CVL group had a higher 90-day mortality rate (7.0% versus 0.0%, p = 0.019). Four out of five deceased patients suffered from aspiration with consecutive respiratory failure. There was a tendency towards delayed gastric emptying in the CME/CVL group (12.7% versus 7.1%, p = 0.246). Clavien-Dindo complication grades ≥ 2 were similar in both groups with 16 (19%) in the conventional and 15 (21.1%) in the CME/CVL group (p = 0.747). CME/CVL patients had a shorter mean length of stay with 11 versus 14 days (p <  0.001). CONCLUSIONS: Complete mesocolic excision with central vascular ligation in right colectomy seems to have a higher aspiration rate leading to severe respiratory failure and to higher mortality compared to conventional resection methods. Patient selection for this procedure may therefore be crucial.

Prior experience in laparoscopic rectal surgery can minimise the learning curve for robotic rectal resections: a cumulative sum analysis.

BACKGROUND: The learning curve for robotic colorectal surgery is ill-defined. This study aimed to investigate the learning curve of experienced laparoscopic rectal surgeons when starting with robotic total mesorectal excision (TME) using cumulative sum (CUSUM) charts. METHODS: This retrospective case series analysed patients who underwent curative and elective laparoscopic or robotic TMEs for rectal cancer performed by two surgeons. The first consecutive robotic TME cases of each surgeon were 1:1 propensity score matched to their laparoscopic TME cases using age, body mass index, American Society of Anesthesiologists grade, T stage (AJCC) and tumour location height. The matched laparoscopic cases defined individual standards for the quality indicators: operating time, R stage, lymph node harvest, length of hospital stay and major complications (Clavien-Dindo grade 3-5). Deviation of more than a quarter of a standard deviation from the mean for the continuous indicators, or exceeding the observed risk for the binary indicators was defined as off-target with an upward inflection in the CUSUM curve. RESULTS: From 2006 to 2015, 384 (294 laparoscopic; 90 robotic) TMEs met the inclusion criteria. Surgeon A performed 206 (70.1%) of the laparoscopic and 43 (47.8%) of the robotic cases. Surgeon B performed 88 (29.9%) of the laparoscopic and 47 (52.2%) of the robotic cases. After matching, no covariate exhibited an absolute standardised mean difference >0.25. For surgeon A, the CUSUM curves showed no apparent learning process compared to his laparoscopic standards. For surgeon B, a learning process for operation time, lymph node harvest and major complications was demonstrated by an initial upward inflection of the CUSUM curves; after 15 cases, all quality indicators were generally on target. CONCLUSIONS: For experienced laparoscopic colorectal surgeons, the formal learning process for robotic TME may be short to reach a similar performance level as obtained in conventional laparoscopy.

Laparoscopic-assisted abdominoperineal resection for low rectal cancer provides a shorter length of hospital stay while not affecting the recurrence or survival: a propensity score-matched analysis.

PURPOSE: To compare the short- and intermediate-term outcomes of open versus laparoscopic abdominoperineal resection (APR) for low rectal cancer. METHODS: Elective open and laparoscopic APRs were identified in a prospective database and were 1:1 propensity score-matched for age, ASA grade, tumour stage and type of neoadjuvant therapy. The short- and intermediate-term outcomes were compared. RESULTS: From January 2003 until June 2013, a total of 135 APRs (87 open, 48 laparoscopic) were identified and matched (n = 96, standardised mean difference of covariates <0.25). The thirty-day mortality, R0 rate, lymph nodes harvested and reoperations were similar. The length of the hospital stay was shorter in the laparoscopic group [10 versus 14 days, p = 0.004 (Mann-Whitney U test), Bonferroni-corrected significance level = 0.0083]. The median follow-up was 4.6 (IQR: 2.0-6.0) years. The overall and recurrence-free 3-year survival rate estimates (Kaplan-Meier method; 95 % CI in brackets) were 71 % (59-86) and 57 % (44-73) in the open group versus 78 % (66-92) and 72 % (60-87) in the laparoscopic group, respectively [p = 0.167 and p = 0.186 (log-rank test), respectively]. The 3-year cumulative incidence of recurrence was 27 % (15-40) in the open group and 16 % (8-29) in the laparoscopic group [p = 0.359 (Gray's test)]. CONCLUSIONS: Compared to open APR, laparoscopic APR provided a shorter length of hospital stay while showing no intermediate-term differences in the survival or cumulative incidence of recurrence.

Short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis.

PURPOSE: To compare the outcomes of colonic splenic flexure tumours treated by extended right colectomy versus left colectomy. METHODS: Stage I-III splenic flexure tumours, treated either by extended right colectomy or left colectomy between 1996 and 2011, were identified in a prospective database, and the short- and long-term outcomes compared. The survival analyses were performed using the Kaplan-Meier method and adjusted using a Cox-proportional hazard model. RESULTS: A total of 30 (44 %) splenic flexure tumours were resected by left colectomy and 38 (56 %) by right colectomy. Emergency operations were more common (74 versus 20 %, p < 0.001) in the right colectomy group. In the univariate analysis, the 5-year overall survival (55 % for right colectomy versus 60 % for left colectomy, p = 0.197) and 5-year recurrence-free survival (41 versus 54 %, p = 0.180, respectively) showed a trend towards a non-significant survival benefit for left colectomy. However, when adjusted for age, gender, ASA classification, tumour stage, urgency and year of surgery, this trend disappeared. CONCLUSION: Patients undergoing extended right or left colectomy for splenic flexure tumours seemed to have comparable short- and long-term outcomes.

Percutaneous transluminal angioplasty of infrainguinal vein graft stenosis is not a negative predictor for long-term patency.

BACKGROUND: To investigate whether maintenance percutaneous transluminal angioplasty (PTA) for significant stenosis after infrainguinal bypass grafting affects long-term patency of the bypass grafts in comparison to those not needing intervention. PATIENTS AND METHODS: The cohort includes 141 consecutive patients with 157 infrainguinal vein grafts performed from January 1996 to December 2005. Grafts occluded within three months after operation were excluded. Revascularisations needing maintenance PTA for significant stenoses of graft or adjacent in- or outflow vessels (intervention group, n = 39) were compared to those not needing intervention during follow up (non-intervention group, n = 118). Primary end point was bypass occlusion. Secondary end points were major amputation or death. Long-term patency in the intervention and non-intervention groups was estimated using Kaplan-Meier curves and compared using the Tarone-Ware test. RESULTS: In the intervention group, primary assisted patency rate after 36 and 60 months was 94.1 % and 89.4 %, respectively, whereas in the non-intervention group patency rate was 92.5 % and 91.0 %, respectively (p = 0.644). Comparing the intervention group to the non-intervention group, 1 versus 2 major amputations (p = 0.642) and 14 versus 40 deaths (p = 0.233) occurred. CONCLUSIONS: Occurrence of graft stenosis did not decrease long-term patency rate when treated by PTA in comparison to grafts not needing maintenance PTA.

Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study.

BACKGROUND: Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies. METHODS: The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan-Meier curves. RESULTS: During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3-4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35-76) in the laparoscopic group versus 43 % (95 % CI 32-58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20-60) versus 37 % (95 % CI 27-50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy. CONCLUSIONS: Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.