Abstract
Background and Objectives:
The traditional open approach is still a common option for colectomy and the most common option chosen for rectal resections for cancer. Randomized trials and large database studies have reported the merits of the minimally invasive approach, while studies comparing laparoscopic and robotic options have reported inconsistent results.
Methods:
This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in protocol-driven regional and national databases. Logistic and multiple linear regression analyses were used to compare standard 30-day colorectal outcomes in the Michigan Surgical Quality Collaborative (MSQC) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases. The primary outcome was overall complications.
Results:
A total of 10,054 MSQC patients (open 37.5%, laparoscopic 48.8%, and robotic 13.6%) and 80,535 ACS-NSQIP patients (open 25.0%, laparoscopic 67.1%, and robotic 7.9%) met inclusion criteria. Overall complications and surgical site infections were significantly favorable for the laparoscopic and robotic approaches compared with the open approach. Anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach in ACS-NSQIP, while there was no significant difference between robotic and open approaches in MSQC. Laparoscopic complications were significantly less than robotic complications in MSQC but significantly more in ACS-NSQIP. Laparoscopic 30-day mortality was significantly less than for the robotic approach in MSQC, but there was no difference in ACS-NSQIP.
Conclusion:
Minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. Individual complication comparisons vary between databases, and caution should be exercised when interpreting results in context.
Keywords: Minimally invasive, Laparoscopic, Robotic, Colorectal surgery
INTRODUCTION
Multiple studies have shown favorable short-term minimally invasive (MIS) colorectal surgery outcomes compared with the open colectomy (OC) approach.1–5 Even so, adoption of the laparoscopic colectomy (LC) method plateaued at 22–55% of colorectal procedures, resulting in the evolution, adoption, and critical analysis of the robotic colectomy (RC) platform.6–8
As MIS options continue to evolve beyond current LC limitations and RC learning curves, studies designed to compare surgical options help determine the current role for each approach. Although randomized trials are considered the optimal study design, they are limited in colorectal surgery to MIS surgeons who have unique expertise and whose results may not be generalizable.9,10 Large risk-adjusted databases offer power in comparison and are potentially generalizable due to large patient numbers contributed by surgeons with varying skill sets and expertise, but these databases are also limited by the reliability of data abstraction and interpretation and lack of certain details.
The purpose of this study was to compare the results of OC, LC, and RC colorectal surgery outcomes in a large regional risk-adjusted and a large national risk-adjusted database.
METHODS
This study is a retrospective outcomes comparison of OC, LC, and RC colorectal surgery using data from the national American College of Surgeons-National Surgical Quality Program (ACS-NSQIP) database from January 1, 2012, through December 31, 2016, and from the regional 72-hospital Michigan Surgical Quality Collaborative (MSQC) database from July 1, 2012, through August 20, 2017. Both risk-adjusted databases employ certified and trained data abstractors who collect patient demographics and preoperative and 30-day postoperative information on surgical patients. This study was approved by the Institutional Review Board at Saint Joseph Mercy Health System, Ann Arbor, Michigan.
Inclusion Criteria
The following CPT codes were used to query cases: OC (44140, 44160), open pelvic operations (44145, 44146, 45110), MIS colectomy (44204, 44205), and MIS pelvic operations (44207, 44208, 45395). Both MSQC and NSQIP database dictionaries distinguish LC from RC cases. Exclusion criteria were pediatric patients (younger than 18 years), urgent and emergent operations, and patients with American Society of Anesthesiologists (ASA) classification of 5 (moribund) or 6 (brain death). The study was designed to compare MIS completed operations, so LC and RC converted cases were excluded.
Variables for Statistical Model
Preoperative variables for both databases included age, sex, body mass index (BMI), and race/ethnicity. Comorbidities included tobacco use, diabetes, ventilator dependence, hypertension, congestive heart failure, chronic obstructive pulmonary disease, ascites, disseminated cancer, weight loss (>10% in the past 6 months), presence of bleeding disorders, diagnosis (colorectal cancer, colorectal adenomas/polyps, diverticular disease, other), and ASA classification. Both databases also included a variable for operative time, which was considered as a covariate except for the model in which operative time 100 minutes was the outcome. The MSQC database additionally included history of sleep apnea, deep vein thrombosis (DVT), coronary artery disease (CAD), peripheral vascular disease, steroid use, history of alcohol abuse, hospital volume, and surgeon volume. The ACS-NSQIP database also included location of surgery (right colectomy, sigmoid colectomy, total colectomy, or rectal resection).
Outcomes
The primary outcome in this study was overall 30-day complications. Secondary outcomes of interest were hospital length of stay (LOS), operative time, surgical site infections (SSIs), urinary tract infections (UTIs), DVT, cardiac complications, pneumonia, unplanned intubation, renal failure, anastomotic leaks, 30-day readmission, 30-day reoperation, discharge destination not home, and 30-day mortality. Operative time was defined as the duration of operation from skin incision to skin closure. Anastomotic leak was defined as extravasation of contrast medium at computed tomography scan or contrast enema.
Statistical Analysis
Patients in the OC, LC, and RC groups were compared by demographics and presurgical health histories with the use of χ2 tests for categorical variables and t-tests for interval variables. Given the significant differences in patient backgrounds, logistic (categorical outcomes) and linear (continuous outcome) regression analyses were performed that adjusted for the pretreatment variables. The results of the logistic regressions are summarized by using odds ratios (ORs) and the corresponding 95% confidence intervals (CIs). Significant differences in outcomes between surgery types are identified when the 95% CIs do not include 1. The results of the linear regression analyses are summarized with the estimated slope and the corresponding 95% CI. Significant differences are identified when the 95% CI around the estimated slope does not include 0.
RESULTS
A total of 10,054 MSQC patients (3775 [37.6%] OC, 4908 [48.8%] LC, and 1371 [13.6%] RC) and 80,535 ACS-NSQIP patients (20,116 [25.0%] OC, 54,077 [67.1%] LC, and 6342 [7.9%] RC) met inclusion criteria. Patient characteristics for both MSQC and ACS-NSQIP groups are depicted in Table 1 and are summarized in the following. There were significant differences in all measured MSQC and ACS-NSQIP patient characteristics except alcohol use and ventilator dependence in the MSQC population. MSQC/ACS-NSQIP BMI ≥30 kg/m2 accounted for 38.1%/33.9% of OC, 38.2%/35.0% of LC, and 39.5%/37.6% of RC cases, respectively. The OC group in both MSQC and ACS-NSQIP had significantly more patients of ASA 3/4 categories. Colorectal neoplasia and diverticular disease constituted 54.5% and 24.1% of the MSQC and 53.9% and 22.3% of the ACS-NSQIP patient populations, respectively. Rectal resections constituted a significantly larger proportion of cases in the RC group compared with the OC and LC groups (OC 33.2%, LC 29.6%, RC 48.4%).
Table 1.
Patient Characteristics
| Covariate | MSQC (n = 10,054) |
p-value† | NSQIP (n = 80,535) |
p-value† | ||||
|---|---|---|---|---|---|---|---|---|
| Open (n = 3,775) | Lap (n = 4,908) | Robot (n = 1,371) | Open (n = 20,116) | Lap (n = 54,077) | Robot (n = 6,342) | |||
| Age, mean (SD) | 64 (13.8) | 62 (13.4) | 61 (12.9) | <0.0001* | 62 (14.7) | 60 (14.5) | 60 (12.9) | <0.0001* |
| BMI, n (%) | 0.0002* | <0.0001* | ||||||
| <18.5 or Unknown | 117 (3.1) | 113 (2.3) | 15 (1.1) | 731 (3.6) | 1226 (2.3) | 85 (1.3) | ||
| 18.5–24.9 | 983 (26.0) | 1206 (24.6) | 346 (25.2) | 6094 (30.3) | 15170 (28.1) | 1664 (26.2) | ||
| 25–29.9 | 1236 (32.7) | 1717 (35.0) | 469 (34.2) | 6470 (32.2) | 18783 (34.7) | 2204 (34.8) | ||
| 30–34.9 | 796 (21.1) | 1103 (22.5) | 290 (21.2) | 3820 (19) | 11400 (21.1) | 1430 (22.5) | ||
| >= 35 | 643 (17.0) | 769 (15.7) | 251 (18.3) | 3001 (14.9) | 7498 (13.9) | 959 (15.1) | ||
| Male Gender, n (%) | 1679 (44.5) | 2321 (47.3) | 681 (49.7) | 0.0015* | 9413 (46.8) | 25866 (47.8) | 3179 (50.1) | <0.0001* |
| Race, n (%) | 0.0002* | <0.0001* | ||||||
| Caucasian | 3224 (85.4) | 4158 (84.7) | 1185 (86.4) | 15404 (76.6) | 42061 (77.8) | 5276 (83.2) | ||
| African American | 431 (11.4) | 506 (10.3) | 125 (9.1) | 1777 (8.8) | 4455 (8.2) | 497 (7.8) | ||
| Asian | 459 (2.3) | 1666 (3.1) | 206 (3.2) | |||||
| Other | 120 (3.2) | 244 (5.0) | 61 (4.4) | 2476 (12.3) | 5895 (10.9) | 363 (5.7) | ||
| Partially/Totally Dependent, n (%) | 126 (3.3) | 83 (1.7) | 9 (0.7) | <0.0001* | 388 (1.9) | 530 (1) | 43 (0.7) | <0.0001* |
| Tobacco Use, n (%) | 849 (22.5) | 962 (19.6) | 300 (21.9) | 0.0032* | 3561 (17.7) | 8312 (15.4) | 956 (15.1) | <0.0001* |
| Alcohol Use, n (%) | 129 (3.4) | 151 (3.1) | 42 (3.1) | 0.6383 | ||||
| Steroids, n (%) | 233 (6.2) | 199 (4.1) | 52 (3.8) | <0.0001* | ||||
| Diabetes, n (%) | 798 (21.1) | 887 (18.1) | 256 (18.7) | 0.0013* | 3118 (15.5) | 7435 (13.7) | 955 (15.1) | <0.0001* |
| Ventilator Dependent, n (%) | 2 (0.1) | 3 (0.1) | 0 (0.0) | 0.6642 | 11 (0.1) | 4 (0) | 0 (0) | 0.0004* |
| Hypertension, n (%) | 2173 (57.6) | 2578 (52.5) | 715 (52.2) | <0.0001* | 9685 (48.1) | 24788 (45.8) | 2946 (46.5) | <0.0001* |
| Coronary Artery Disease | 657 (17.4) | 635 (12.9) | 183 (13.3) | <0.0001* | ||||
| CHF, n (%) | 32 (0.8) | 13 (0.3) | 5 (0.4) | 0.0005* | 170 (0.8) | 257 (0.5) | 19 (0.3) | <0.0001* |
| COPD | 411 (10.9) | 364 (7.4) | 114 (8.3) | <0.0001* | 1019 (5.1) | 2094 (3.9) | 210 (3.3) | <0.0001* |
| Sleep Apnea | 542 (14.4) | 817 (16.6) | 248 (18.1) | 0.0011* | ||||
| Peripheral Vascular Disease, n (%) | 129 (3.4) | 91 (1.9) | 21 (1.5) | <0.0001* | ||||
| DVT | 272 (7.2) | 224 (4.6) | 53 (3.9) | <0.0001* | ||||
| Ascites, n (%) | 29 (0.8) | 6 (0.1) | 0 (0.0) | <0.0001* | 155 (0.8) | 62 (0.1) | 3 (0) | <0.0001* |
| Disseminated Cancer, n (%) | 0 (0.0) | 0 (0.0) | 0 (0.0) | - | 2290 (11.4) | 1611 (3) | 218 (3.4) | <0.0001* |
| Weight Loss >10%, n (%) | 169 (4.5) | 100 (2.0) | 39 (2.8) | <0.0001* | 1073 (5.3) | 1439 (2.7) | 121 (1.9) | <0.0001* |
| Bleeding Disorder, n (%) | 139 (3.7) | 95 (1.9) | 19 (1.4) | <0.0001* | 588 (2.9) | 1016 (1.9) | 118 (1.9) | <0.0001* |
| Diagnosis, n (%) | <0.0001* | <0.0001* | ||||||
| Colorectal Cancer | 1706 (45.2) | 1858 (37.9) | 597 (43.5) | 8853 (44) | 22112 (40.9) | 3101 (48.9) | ||
| Colorectal Adenomas/Polyps | 348 (9.2) | 806 (16.4) | 163 (11.9) | 1190 (5.9) | 8147 (15.1) | 724 (11.4) | ||
| Diverticular Disease/Fistulas | 751 (19.9) | 1329 (27.1) | 341 (24.9) | 2887 (14.4) | 13121 (24.3) | 1772 (27.9) | ||
| Other | 970 (25.7) | 915 (18.6) | 270 (19.7) | 7186 (35.7) | 10697 (19.8) | 745 (11.7) | ||
| ASA Classification, n (%) | <0.0001* | <0.0001* | ||||||
| ASA 1 or 2 | 1426 (37.8) | 2537 (51.7) | 732 (53.4) | 8108 (40.3) | 30152 (55.8) | 3340 (52.7) | ||
| ASA 3 | 2140 (56.7) | 2226 (45.4) | 613 (44.7) | 11058 (55) | 22540 (41.7) | 2895 (45.6) | ||
| ASA 4 | 209 (5.5) | 145 (3.0) | 26 (1.9) | 950 (4.7) | 1385 (2.6) | 107 (1.7) | ||
| Operative Segment n (%) | <0.0001* | |||||||
| Abdominal, Right | 5265 (26.2) | 12857 (23.8) | 1122 (17.7) | |||||
| Abdominal, Sigmoid | 7108 (35.3) | 22790 (42.1) | 2023 (31.9) | |||||
| Abdominal, Total | 1058 (5.3) | 2422 (4.5) | 128 (2) | |||||
| Rectum | 6685 (33.2) | 16008 (29.6) | 3069 (48.4) | |||||
| Surgery Time, mean (SD) | 199 (100.4) | 224 (106.7) | 260 (101.3) | <0.0001* | 187 (112.8) | 176 (83.5) | 228 (96.5) | <0.0001* |
| Hospital Volume, mean (SD) | 199 (100.4) | 224 (106.7) | 260 (101.3) | <0.0001* | ||||
| Surgeon Volume, mean (SD) | 42 (43.7) | 56 (46.4) | 68 (45.1) | <0.0001* | ||||
BMI = Body Mass Index, ASA = American Society of Anesthesiology.
† p values based on Chi-Square test or Kruskal-Wallis test.
*Significant difference, p < 0.05.
Table 2 displays unadjusted MSQC and ACS-NSQIP outcomes that are summarized by the following. The number of operative cases with duration >100 minutes is significantly higher and the hospital LOS is significantly shorter for the patients who received the RC approach.
Table 2.
Unadjusted Postoperative Outcomes by Surgical Approach
| Postoperative Outcome | MSQC |
NSQIP |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Unadjusted Values |
Unadjusted P-Value† |
Unadjusted Values |
Unadjusted P-Value† |
|||||||||
| Open | Lap | Robot | Open vs Lap | Open vs Robot | Lap vs Robot | Open | Lap | Robot | Open vs Lap | Open vs Robot | Lap vs Robot | |
| Hospital Length of Stay, mean days | 7.1 | 4.5 | 4.2 | <0.0001* | <0.0001* | 0.0232* | 8 | 5 | 4 | <0.0001* | <0.0001* | <0.0001* |
| Operative Duration >100 min, n (%) | 2545 (67.4) | 3686 (75.1) | 1241 (90.5) | <0.0001* | <0.0001* | <0.0001* | 16034 (79.7) | 45843 (84.8) | 6034 (95.1) | <0.0001* | <0.0001* | <0.0001* |
| Any Complication, n (%) | 917 (24.3) | 599 (12.2) | 209 (15.4) | <0.0001* | <0.0001* | 0.0089* | 7931 (39.5) | 11013 (20.4) | 1229 (19.4) | <0.0001* | <0.0001* | 0.19 |
| SSI, n (%) | 377 (10.0) | 197 (4.0) | 73 (5.3) | <0.0001* | <0.0001* | 0.1032 | 1731 (8.6) | 1957 (3.6) | 178 (2.8) | <0.0001* | <0.0001* | 0.0031* |
| UTI, n (%) | 115 (3.1) | 57 (1.2) | 20 (1.5) | <0.0001* | 0.0049* | 1.0000 | 638 (3.2) | 864 (1.6) | 91 (1.4) | <0.0001* | <0.0001* | >0.9999 |
| DVT, n (%) | 42 (1.1) | 25 (0.5) | 7 (0.5) | 0.0044* | 0.1479 | 1.0000 | 274 (1.4) | 395 (0.7) | 36 (0.6) | <0.0001* | 0.0001* | 0.504 |
| Any Cardiac Complication, n (%) | 19 (0.5) | 12 (0.2) | 8 (0.6) | 0.1351 | 1.0000 | 0.1467 | 230 (1.1) | 297 (0.5) | 35 (0.6) | <0.0001* | 0.0002* | >0.9999 |
| Pneumonia, n (%) | 91 (2.4) | 32 (0.7) | 13 (1.0) | <0.0001* | 0.0029* | 0.7510 | 447 (2.2) | 522 (1) | 52 (0.8) | <0.0001* | <0.0001* | 0.867 |
| Unplanned Intubation, n (%) | 77 (2.0) | 49 (1.0) | 17 (1.2) | 0.0002* | 0.1747 | 1.0000 | 342 (1.7) | 393 (0.7) | 41 (0.6) | <0.0001* | <0.0001* | >0.9999 |
| Renal Failure or Insufficiency, n (%) | 124 (3.3) | 79 (1.6) | 39 (2.8) | <0.0001* | 1.0000 | 0.0087* | 303 (1.5) | 308 (0.6) | 59 (0.9) | <0.0001* | 0.0022* | 0.0019* |
| Anastomotic Leak††, n (%) | 94 (2.7) | 79 (1.6) | 35 (2.7) | 0.0033* | 1.0000 | 0.0299* | 818 (4.3) | 1314 (2.6) | 178 (2.9) | <0.0001* | <0.0001* | 0.423 |
| Readmission within 30 Days, n (%) | 472 (12.5) | 381 (7.8) | 135 (9.9) | <0.0001* | 0.0270* | 0.0390* | 2515 (12.5) | 4165 (7.7) | 533 (8.4) | <0.0001* | <0.0001* | 0.153 |
| Reoperation within 30 Days, n (%) | 304 (8.1) | 266 (5.4) | 103 (7.5) | <0.0001* | 1.0000 | 0.0107* | 1037 (5.2) | 1853 (3.4) | 271 (4.3) | <0.0001* | 0.0157* | 0.0018 |
| Not Discharged Home, n (%) | 1251 (33.1) | 658 (13.4) | 352 (25.7) | <0.0001* | <0.0001* | <0.0001* | 1037 (5.2) | 1853 (3.4) | 271 (4.3) | <0.0001* | <0.0001* | 0.137 |
| Death within 30 Day, n (%) | 55 (1.5) | 21 (0.4) | 12 (0.9) | <0.0001* | 0.3110 | 0.1284 | 222 (1.1) | 222 (0.4) | 19 (0.3) | <0.0001* | <0.0001* | 0.666 |
†p-values based on Chi-Square test or Least Squares Means test and includes Bonferroni correction for multiple comparisons.
*Significant difference, p < 0.05.
OC vs LC
Overall complications and all other OC-vs-LC outcomes are significantly different in favor of the LC approach expect for cardiac complications in the MSQC database, where there is no significant difference.
OC vs RC
Overall complications and all other OC-vs-RC ACS-NSQIP outcomes are significantly different in favor of the RC approach. Significantly different outcomes in the ACS-NSQIP database that are not significantly different in MSQC are given for DVT, cardiac complications, unplanned reintubation, renal failure, anastomotic leak, 30-day reoperation, and 30-day mortality.
LC vs RC
The overall complication rate is significantly less for the LC group than for the RC group in the MSQC database, while there is no significant difference in the ACS-NSQIP database analysis. SSIs are significantly fewer for the RC approach in ACS-NSQIP but not in MSQC. Anastomotic leaks and 30-day readmissions are significantly less with the LC approach compared with the RC approach in MSQC, but there is no significant difference in ACS-NSQIP. There are significantly fewer 30-day reoperations for the LC group compared with the RC group in both databases.
Table 3 and Figure 1 show ORs for MSQC and ACS-NSQIP adjusted outcomes for the colorectal study group. Table 4 and Figure 2 show subgroup analyses of ORs for MSQC and ACS-NSQIP risk-adjusted outcomes for colectomies, and Table 5 and Figure 3 provide the same for rectal resections. These tables and figures are summarized as follows.
Table 3.
Risk Adjusted Postoperative Outcomes by Surgical Approach
| Postoperative Outcome | MSQC (n = 10,054) |
ACS-NSQIP (n = 80,535) |
MSQC (n = 10,054) |
ACS-NSQIP (n = 80,535) |
MSQC (n = 10,054) |
ACS-NSQIP (n = 80,53 5) |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Open vs Lap |
Open vs Robot |
Lap vs Robot |
||||||||||||||||
| Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | |||||||
| Continous | ||||||||||||||||||
| Hospital Length of Stay | 2.6150 | 2.4476 | 2.7823 | 2.219 | 2.131 | 2.307 | 2.9359 | 2.6922 | 3.1796 | 2.977 | 2.826 | 3.128 | 0.3209 | 0.0848 | 0.5570 | 0.759 | 0.622 | 0.896 |
| Binary | ||||||||||||||||||
| Operative Duration >100 min | 0.5294 | 0.4816 | 0.5820 | 0.613 | 0.586 | 0.641 | 0.1893 | 0.1560 | 0.2297 | 0.2 | 0.177 | 0.226 | 0.3576 | 0.2946 | 0.4340 | 0.326 | 0.29 | 0.368 |
| Any Complication | 1.6149 | 1.4424 | 1.8081 | 2.098 | 2.021 | 2.178 | 1.3370 | 1.1352 | 1.5747 | 2.502 | 2.327 | 2.69 | 0.8279 | 0.7022 | 0.9761 | 1.192 | 1.113 | 1.277 |
| SSI | 2.1091 | 1.7689 | 2.5148 | 2.328 | 2.169 | 2.498 | 1.7604 | 1.3548 | 2.2874 | 3.222 | 2.744 | 3.784 | 0.8347 | 0.6353 | 1.0966 | 1.384 | 1.183 | 1.619 |
| UTI | 1.9429 | 1.4159 | 2.6662 | 1.636 | 1.466 | 1.825 | 1.6831 | 1.0466 | 2.7067 | 2.028 | 1.615 | 2.546 | 0.8663 | 0.5284 | 1.4202 | 1.24 | 0.994 | 1.547 |
| DVT | 1.5932 | 0.9730 | 2.6087 | 1.527 | 1.295 | 1.8 | 1.7883 | 0.8009 | 3.9933 | 2.034 | 1.424 | 2.906 | 1.1225 | 0.4954 | 2.5436 | 1.334 | 0.943 | 1.887 |
| Any Cardiac Complication | 1.2999 | 0.6264 | 1.2531 | 1.59 | 1.325 | 1.908 | 0.4878 | 0.2208 | 1.0774 | 1.598 | 1.106 | 2.311 | 0.3752 | 0.1699 | 0.8286 | 1.005 | 0.702 | 1.439 |
| Pneumonia | 2.6007 | 1.7502 | 3.8646 | 1.714 | 1.497 | 1.963 | 1.7974 | 1.0286 | 3.1409 | 1.908 | 1.416 | 2.57 | 0.6911 | 0.3786 | 1.2616 | 1.113 | 0.831 | 1.49 |
| Unplanned Intubation | 1.3585 | 0.9466 | 1.9538 | 1.721 | 1.474 | 2.009 | 1.0033 | 0.6122 | 1.6441 | 1.962 | 1.403 | 2.743 | 0.7385 | 0.4496 | 1.2131 | 1.141 | 0.821 | 1.586 |
| Renal Failure or Insufficiency | 1.5324 | 1.1542 | 2.0347 | 2.038 | 1.722 | 2.412 | 0.9870 | 0.6801 | 1.4323 | 1.501 | 1.123 | 2.006 | 0.8279 | 0.4404 | 0.9419 | 0.736 | 0.553 | 0.98 |
| Anastomotic Leak | 1.4851 | 1.0978 | 2.0092 | 1.496 | 1.362 | 1.644 | 0.9500 | 0.6367 | 1.4175 | 1.498 | 1.263 | 1.776 | 0.8279 | 0.4272 | 0.9580 | 1.002 | 0.852 | 1.179 |
| Readmission within 30 Days | 1.3364 | 1.1592 | 1.5407 | 1.436 | 1.36 | 1.517 | 1.1564 | 0.9422 | 1.4194 | 1.42 | 1.283 | 1.573 | 0.8653 | 0.7055 | 1.0613 | 0.989 | 0.898 | 1.089 |
| Reoperation within 30 Days | 1.2073 | 1.0177 | 1.4322 | 1.3 | 1.197 | 1.411 | 0.9533 | 0.7527 | 1.2072 | 1.105 | 0.96 | 1.273 | 0.7896 | 0.6254 | 0.9968 | 0.85 | 0.744 | 0.972 |
| Not Discharged Home | 2.1450 | 1.9323 | 2.3811 | 2.038 | 1.892 | 2.196 | 1.2790 | 1.1086 | 1.4756 | 2.487 | 2.118 | 2.92 | 0.5963 | 0.5152 | 0.6901 | 1.22 | 1.041 | 1.43 |
| Death within 30 Day | 2.1680 | 1.3198 | 3.5625 | 1.713 | 1.402 | 2.092 | 0.9092 | 0.5134 | 1.6101 | 2.028 | 1.252 | 3.284 | 0.4193 | 0.2251 | 0.7810 | 1.184 | 0.734 | 1.91 |
Note: Estimates for continuous outcomes are mean differences from multiple regression. Estimates for binary outcomes are odds ratios from logistic regressions.
CI = Confidence Intervals.
Bold indicates significance.
Figure 1.
Outcomes for all patients: OC vs LC, OC vs RC, and LC vs RC.
Table 4.
Risk Adjusted Postoperative Outcomes by Surgical Approach for Colectomy Patients
| Postoperative Outcome | MSQC (n = 7,044) |
ACS-NSQIP (n = 54,773) |
MSQC (n = 7,044) |
ACS-NSQIP (n = 54,773) |
MSQC (n = 7,044) |
ACS-NSQIP (n = 54,773) |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Open vs Lap |
Open vs Robot |
Lap vs Robot |
||||||||||||||||
| Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | |||||||
| Continuous | ||||||||||||||||||
| Hospital Length of Stay | 2.3885 | 2.1947 | 2.5823 | 2.249 | 2.141 | 2.357 | 2.9184 | 2.6194 | 3.2173 | 3.208 | 3.002 | 3.414 | 0.5299 | 0.2425 | 0.8172 | 0.959 | 0.769 | 1.149 |
| Binary | ||||||||||||||||||
| Operative Duration >100 min | 0.4915 | 0.4412 | 0.5477 | 0.606 | 0.576 | 0.638 | 0.2345 | 0.1903 | 0.2889 | 0.176 | 0.151 | 0.204 | 0.4770 | 0.3878 | 0.5866 | 0.29 | 0.25 | 0.336 |
| Any Complication | 1.4790 | 1.2901 | 1.6956 | 2.119 | 2.026 | 2.217 | 1.2460 | 1.0100 | 1.5372 | 2.68 | 2.426 | 2.962 | 0.8425 | 0.6844 | 1.0370 | 1.265 | 1.149 | 1.392 |
| SSI | 1.9368 | 1.5570 | 2.4092 | 2.264 | 2.077 | 2.468 | 1.6949 | 1.1929 | 2.4081 | 3.031 | 2.443 | 3.761 | 0.8751 | 0.6114 | 1.2525 | 1.339 | 1.084 | 1.655 |
| UTI | 1.9962 | 1.3262 | 3.0049 | 1.621 | 1.408 | 1.867 | 2.1732 | 1.0510 | 4.4935 | 1.839 | 1.338 | 2.526 | 1.0886 | 0.5176 | 2.2899 | 1.134 | 0.832 | 1.546 |
| DVT | 2.0557 | 1.1246 | 3.7576 | 1.568 | 1.297 | 1.897 | 2.5357 | 0.8123 | 7.9152 | 2.354 | 1.442 | 3.842 | 1.2335 | 0.3847 | 3.9555 | 1.501 | 0.928 | 2.426 |
| Cardiac Complications | 1.1527 | 0.5052 | 2.6304 | 1.578 | 1.269 | 1.961 | 0.3670 | 0.1496 | 0.9000 | 1.829 | 1.08 | 3.099 | 0.3183 | 0.1356 | 0.7475 | 1.16 | 0.692 | 1.942 |
| Pneumonia | 2.4201 | 1.5320 | 3.8231 | 1.684 | 1.439 | 1.97 | 1.4062 | 0.7397 | 2.6733 | 2.366 | 1.558 | 3.591 | 0.5811 | 0.2942 | 1.1478 | 1.406 | 0.934 | 2.118 |
| Unplanned Intubation | 1.3216 | 0.8708 | 2.0058 | 1.829 | 1.531 | 2.187 | 0.7722 | 0.4439 | 1.3433 | 2.098 | 1.366 | 3.223 | 0.5843 | 0.3384 | 1.0088 | 1.147 | 0.751 | 1.751 |
| Renal Failure/Insufficiency | 1.6180 | 1.1378 | 2.3010 | 2.081 | 1.674 | 2.587 | 1.1077 | 0.6678 | 1.8376 | 1.784 | 1.11 | 2.867 | 0.6846 | 0.4103 | 1.1423 | 0.858 | 0.538 | 1.368 |
| Anastomotic Leak | 1.2443 | 0.8654 | 1.7892 | 1.669 | 1.481 | 1.881 | 0.8811 | 0.5282 | 1.4699 | 2.217 | 1.678 | 2.928 | 0.7081 | 0.4288 | 1.1694 | 1.328 | 1.016 | 1.738 |
| Readmission within 30 Days | 1.2964 | 1.0877 | 1.5451 | 1.451 | 1.354 | 1.554 | 1.2442 | 0.9434 | 1.6408 | 1.567 | 1.355 | 1.811 | 0.9597 | 0.7309 | 1.2603 | 1.08 | 0.94 | 1.241 |
| Reoperation within 30 Days | 1.1454 | 0.9249 | 1.4186 | 1.401 | 1.267 | 1.548 | 0.9858 | 0.7158 | 1.3577 | 1.257 | 1.03 | 1.536 | 0.8607 | 0.6305 | 1.1749 | 0.898 | 0.744 | 1.083 |
| Not Discharged Home | 2.0019 | 1.7525 | 2.2868 | 2.038 | 1.866 | 2.226 | 1.2137 | 1.0008 | 1.4720 | 2.452 | 1.984 | 3.03 | 0.6063 | 0.4990 | 0.7367 | 1.203 | 0.976 | 1.484 |
| Death within 30 Day | 2.7455 | 1.5286 | 4.9314 | 1.811 | 1.449 | 2.265 | 0.7284 | 0.3916 | 1.3550 | 1.744 | 0.997 | 3.048 | 0.2653 | 0.1318 | 0.5341 | 0.963 | 0.554 | 1.673 |
Note: Estimates for continuous outcomes are mean differences from multiple regression. Estimates for binary outcomes are odds ratios from logistic regressions.
CI = Confidence Interval.
Bold indicates significance.
Figure 2.
Colectomy outcomes for OC vs LC, OC vs RC, and LC vs RC.
Table 5.
Risk Adjusted Postoperative Outcomes by Surgical Approach for Rectal Resection Patients
| Postoperative Outcome | MSQC (n = 3,010) |
ACS-NSQIP (n = 25,762) |
MSQC (n = 3,010) |
ACS-NSQIP (n = 25,762) |
MSQC (n = 3,010) |
ACS-NSQIP (n = 25,762) |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Open vs Lap | Estimate | 95% CI | Open vs Robot | Estimate | 95% CI | Lap vs Robot | Estimate | 95% CI | ||||||||||
| Estimate | 95% CI | Estimate | 95% CI | Estimate | 95% CI | |||||||||||||
| Continuous | ||||||||||||||||||
| Total Hospital Length of Stay | 3.0210 | 2.6931 | 3.3488 | 2.146 | 1.993 | 2.299 | 2.708 | 2.483 | 2.933 | 3.1054 | 2.6822 | 3.5287 | 0.0844 | -0.3383 | 0.5072 | 0.562 | 0.362 | 0.762 |
| Binary | ||||||||||||||||||
| Operative Duration >100 min | 0.5772 | 0.4662 | 0.7148 | 0.58 | 0.524 | 0.643 | 0.265 | 0.215 | 0.327 | 0.1307 | 0.0799 | 0.2138 | 0.2264 | 0.1372 | 0.3733 | 0.456 | 0.373 | 0.558 |
| Any Complication | 1.9748 | 1.6051 | 2.4296 | 2.052 | 1.92 | 2.194 | 2.321 | 2.088 | 2.58 | 1.4376 | 1.1123 | 1.8582 | 0.7280 | 0.5539 | 0.9568 | 1.131 | 1.023 | 1.25 |
| SSI | 2.3682 | 1.7414 | 3.2206 | 2.469 | 2.174 | 2.805 | 3.442 | 2.705 | 4.38 | 1.7120 | 1.1735 | 2.4977 | 0.7229 | 0.4757 | 1.0987 | 1.392 | 1.098 | 1.765 |
| UTI | 1.7909 | 1.0786 | 2.9735 | 1.619 | 1.355 | 1.935 | 2.266 | 1.637 | 3.137 | 1.3023 | 0.7059 | 2.4026 | 0.7272 | 0.3737 | 1.4152 | 1.399 | 1.021 | 1.919 |
| DVT | 1.2752 | 0.5390 | 3.0172 | 1.435 | 1.024 | 2.01 | 1.626 | 0.948 | 2.787 | 1.4150 | 0.4335 | 4.6184 | 1.1096 | 0.3281 | 3.7525 | 1.133 | 0.678 | 1.894 |
| Cardiac Complications | 2.9514 | 0.4351 | 20.0195 | 1.644 | 1.171 | 2.307 | 1.35 | 0.794 | 2.296 | 1.0986 | 0.1776 | 6.7956 | 0.3722 | 0.0388 | 3.5715 | 0.821 | 0.491 | 1.372 |
| Pneumonia | 4.2601 | 1.7692 | 10.2581 | 1.822 | 1.379 | 2.407 | 1.507 | 0.971 | 2.337 | 2.8236 | 0.9807 | 8.1297 | 0.6628 | 0.1880 | 2.3363 | 0.827 | 0.536 | 1.275 |
| Unplanned Intubation | 1.7223 | 0.7925 | 3.7432 | 1.422 | 1.033 | 1.957 | 1.725 | 0.998 | 2.98 | 1.9138 | 0.6383 | 5.7387 | 1.1112 | 0.3462 | 3.5669 | 1.213 | 0.714 | 2.059 |
| Renal Failure/Insufficiency | 1.6256 | 1.0009 | 2.6403 | 1.998 | 1.53 | 2.608 | 1.405 | 0.962 | 2.051 | 0.9793 | 0.5664 | 1.6934 | 0.6024 | 0.3329 | 1.0904 | 0.703 | 0.485 | 1.021 |
| Anastomotic Leak | 2.2235 | 1.2484 | 3.9602 | 1.244 | 1.065 | 1.452 | 1.078 | 0.86 | 1.35 | 0.9997 | 0.5383 | 1.8564 | 0.4496 | 0.2250 | 0.8986 | 0.866 | 0.702 | 1.068 |
| Readmission within 30 Days | 1.4788 | 1.1548 | 1.8936 | 1.413 | 1.281 | 1.559 | 1.305 | 1.129 | 1.508 | 1.1670 | 0.8586 | 1.5860 | 0.7891 | 0.5725 | 1.0877 | 0.923 | 0.806 | 1.057 |
| Reoperation within 30 Days | 1.2630 | 0.9448 | 1.6884 | 1.102 | 0.951 | 1.276 | 0.919 | 0.745 | 1.133 | 0.9066 | 0.6412 | 1.2819 | 0.7178 | 0.5020 | 1.0264 | 0.834 | 0.69 | 1.009 |
| Not Discharged Home | 2.2533 | 1.8927 | 2.6825 | 2.028 | 1.768 | 2.326 | 2.537 | 1.982 | 3.248 | 1.4555 | 1.1735 | 1.8052 | 0.6459 | 0.5155 | 0.8094 | 1.251 | 0.979 | 1.598 |
| Death within 30 Day | 0.7866 | 0.2982 | 2.0752 | 1.39 | 0.898 | 2.151 | 2.71 | 1.041 | 7.053 | 1.1741 | 0.2892 | 4.7659 | 1.4926 | 0.3833 | 5.8123 | 1.948 | 0.76 | 4.992 |
Note: Estimates for continuous outcomes are mean differences from multiple regression. Estimates for binary outcomes are odds ratios from logistic regressions.
CI = Confidence Intervals.
Bold indicates signficance.
Figure 3.
Rectal resection outcomes for OC vs LC, OC vs RC, and LC vs RC.
Overall Complication Rate
The overall complication rate was significantly higher in the OC group compared with the LC and RC groups, and this finding remained significant in colectomy and rectal resection subgroup analyses. When comparing the LC and RC groups, MSQC and ACS-NSQIP results differed. In the MSQC analysis, there were significantly fewer complications in the LC group and the LC rectal resection subgroup with no significant difference in the colectomy subgroup. In contrast, there were significantly more complications in the LC group compared with the RC group in the ACS-NSQIP analysis, and this finding was also significantly different in both colectomy and rectal resection subgroup analyses.
Operative Times and Hospital LOS
Cases with operative times >100 minutes were significantly longer in the RC group than in the LC and OC groups in both MSQC and ACS-NSQIP databases, and this finding remained significant in colectomy and rectal resection subgroups analyses. Hospital LOS was significantly shorter for the RC group than for the LC and OC groups in both MSQC and ACS-NSQIP databases, and this finding remained significant in the colectomy subgroup analysis. In the rectal resection subgroup, hospital LOS was not significantly different in MSQC.
Individual Complications
SSIs were significantly more common in all OC groups compared with the LC and RC groups in both MSQC and ACS-NSQIP databases. When comparing the LC and RC approaches, SSIs were significantly fewer in the RC group and RC subgroups in ACS-NSQIP, while there was no significant difference between LC and RC groups and subgroups in MSQC.
Anastomotic leaks were significantly more common in all OC groups compared with the LC and RC groups and subgroups in the ACS-NSQIP database. In the MSQC database, anastomotic leaks were significantly more frequent in the OC group than in the LC group except in colectomy subgroups analyses, where there was no significant difference. There was no significant difference in anastomotic leaks in MSQC when comparing the OC and RC groups and subgroups. When comparing the LC and RC groups, MSQC and ACS-NSQIP analyses revealed contrasting results. Anastomotic leaks were significantly fewer in the MSQC LC group and the LC rectal resection subgroup compared with the RC group, and there was no significant difference between the LC and RC colectomy subgroups. In the ACS-NSQIP database, there was no significant difference in anastomotic leaks between the LC and RC groups except in colectomy subgroup analysis, where there were significantly fewer anastomotic leaks in the RC group.
The 30-day mortality was significantly more frequent in the OC group than in the LC group and colectomy subgroups in both MSQC and ACS-NSQIP databases except in the MSQC rectal resection subgroup analysis, where there was no significant difference. There was no significant difference in 30-day mortality between the OC and RC groups and subgroups in MSQC, while 30-day mortality was significantly higher in the OC group compared with the RC groups and subgroups in ACS-NSQIP. When comparing LC and RC approaches, 30-day mortality was significantly less frequent in the LC group and colectomy subgroup. There was no significant difference in the rectal resection subgroup. There was no significant difference in ACS-NSQIP 30-day mortality between the LC and RC groups and subgroups.
The tables and figures reveal several other significant outcomes advantages for the LC and RC approaches compared with the OC group in both MSQC and ACS-NSQIP. In addition, the LC group had significantly fewer 30-day reoperations than the RC group in MSQC and significantly less renal failure complications in both databases.
DISCUSSION
This regional MSCQ and national ACS-NSQIP protocol-driven database analysis comparing traditional OC, LC, and RC colorectal surgery demonstrates several outcomes advantages for the MIS approach. The overall complication rate is significantly higher and hospital LOS is significantly longer for the OC approach. SSIs, anastomotic leaks, and several other individual complications are less frequent with MIS than with OC colorectal surgery. LC is associated with particularly favorable outcomes in the regional MSQC database with significantly fewer anastomotic leaks and less 30-day mortality than RC, findings that are not confirmed in the national ACS-NSQIP database, where there is no significant difference. Another contrasting finding in the comparison of the LC and RC groups is the frequency of SSIs—there is no significant difference in MSQC but SSIs are significantly more frequent in the LC group in ACS-NSQIP.
Determining the role of MIS in colorectal surgery presents several challenges. Although LC colectomy has been clearly demonstrated to have outcomes advantages and to be cost effective compared with the traditional OC approach, it is still considerably underused, with traditional OC surgery still common for colectomies and the most common approach for rectal resections.3,7,11 Randomized trials evaluating MIS approaches are conducted by MIS experts and may not be generalizable.9,10 MIS options are evolving and newer advances may require new studies. Large database analyses add power to comparisons because of patient numbers but have other limitations that are difficult to define, suggesting that care be exercised in interpretation.12,13
Other Studies Comparing MIS and OC Colorectal Approaches
Previous studies have confirmed the significantly decreased complication rates and shorter hospital LOS for the MIS approach compared with the OC approach.3,7 A study matching 67 OC with 67 LC institutional colorectal cases and 45 OC with 45 RC cases in the ACS-NSQIP database found a significantly lower overall complication rate (OC 49.2% vs. LC 22.4%, P < .01; OC 33.3% vs RC 6.7%, P < .01) and hospital LOS (OC 7 vs LC 5 days, P < .01; OC 7 vs. RC 5 days, P < .01) for the MIS approach compared with the OC approach.3 The study was an analysis of the authors' institutional data identified in the ACS-NSQIP database, while our study was a multi-institutional comparison of MSQC and ACS-NSQIP databases. There was an SSI outcome advantage for the LC group but not for the RC group in their study compared with the OC approach.3 Other studies have shown shorter hospital LOS and fewer SSIs for the RC approach compared with the OC approach.14
Colorectal operations were significantly longer for the RC group than for the LC and OC groups in both MSQC and ACS-NSQIP analyses, which is consistent with other studies.1,2,14,15 Although operating times decrease with experience, RC takes time to set up, and the operative dissection is characterized by shorter, slower, articulated movements using 3 arms. The longer RC operation times in these studies were not likely due to more complicated cases and did not appear to be accompanied by worse outcomes.
Other Studies Comparing Specific MIS and OC Colorectal Outcomes
Our study revealed significantly fewer anastomotic leaks for the LC group compared with the OC group in both MSQC and ACS-NSQIP databases and significantly fewer anastomotic leaks for the RC group compared with the OC group in the ACS-NSQIP database, with no significant difference in MSQC. Other studies comparing OC and MIS approaches for anastomotic leaks show inconsistent results, with one study suggesting there are fewer leaks with both RC and LC approaches compared with the OC approach.16
When comparing LC and RC in our study, there were significantly fewer anastomotic leaks for LC in MSQC and more for LC in the ACS-NSQIP colectomy subgroup analysis. Most other studies comparing RC and LC show no difference in leak rates, which vary between 2.7% and 3.9%.1–4,8,15 Anastomotic leak is a major complication of colorectal surgery with high morbidity. Reoperation for anastomotic leaks accounts for 30–40% of deaths after resection for colorectal cancer.17 In our study, unadjusted leak rates for OC, LC, and RC were 2.7%, 1.6%, and 2.7%, respectively, in MSQC and 4.3%, 2.6%, and 2.9%, respectively, in ACS-NSQIP. The anastomotic leak rates in both databases in all groups in this study compare favorably with the rates from other studies, especially in the rectal resection subgroup analysis. It may be that the sample size in our study is so large that the statistically significant difference in these rates is not clinically different for this complication.3,4,8,16 Anastomotic leak rates are associated with several risk factors that are difficult to control for in statistical models. The reasons for inconsistent results in studies to date are not apparent at this time, and definitive conclusions based on these results would be difficult to determine.
Thirty-day mortality was another inconsistent finding between MSQC and ACS-NSQIP databases in our study. LC and RC groups have significantly fewer deaths than the OC group in the ACS-NSQIP database, while there was no significant difference between RC and OC approaches in MSQC. The LC group had significantly fewer deaths than the RC group in MSQC, but there was no significant difference in ACS-NSQIP. Adjusted death rates for OC, LC, and RC options were 1.1%, 0.5%, and 1.2%, respectively, in MSQC, and 0.76%, 0.48%, and 0.41%, respectively, in ACS-NSQIP. Other studies show no significant difference in 30-day mortality between LC and RC with rates for both MIS options between 0.3% and 4.0%.1,2,4,8,16
Other Studies Comparing RC and LC Colorectal Outcomes
Many studies comparing LC and RC MIS options show no significant difference in postoperative complication rates, though several show decreased hospital LOS and conversion rates for RC.1,2,4,6,18–20 Some studies show an advantage related to the intracorporeal anastomosis compared with the extracorporeal anastomosis for both RC and LC options.6,20–22 The learning curve for RC appears to be shorter than that for LC, and the adoption of RC is increasing, especially for rectal resections in the pelvis and for anastomotic suturing that accompanies colectomies.21–25 Because of the ergonomic advantages, the RC approach is more appealing for many surgeons operating in the pelvis.1,2 Our study shows a higher proportion of rectal resections in the study population compared with the LC approach (48.4% vs 29.6%, P < .0001). Because 45–78% of colorectal procedures are still done via the OC approach, there may be value to other MIS options if they result in a decrease in OC colorectal surgery and are associated with favorable outcomes.3,4,6–8 This regional and national database analysis suggests that RC outcomes are significantly favorable compared with OC.
MSQC and ACS-NSQIP databases do not contain cost data, and this metric was not evaluated in this study. Ultimately, cost comparisons will affect the value of MIS options for colorectal surgery. Earlier studies revealed higher RC institutional costs compared with LC costs.3,24–26 Because OC is most prevalent, a cost comparison to this approach is warranted as well. One such ACS-NSQIP study matching institutional data found that the median hospital costs of RC and OC surgery were not significantly different.3 Our group recently demonstrated in an analysis linking MSQC clinical metrics with adjudicated complete claims payments from the Michigan Value Collaborative that episode payments for RC were higher than those for the LC approach but lower than those for the OC approach.27 Other studies that include the cost of healthcare resources are warranted to determine if the cost of RC purchase, maintenance, and supplies is mitigated by the favorable outcomes and potential health care resource advantages compared with OC, especially if significantly increasing the adoption of LC is not practical.28
This study is limited by retrospective design. There is the possibility of selection bias and the possibility of unmeasured confounders, even with statistical adjustment. Data reliability depends on accurate data abstraction, but this may be a strength of the present study in that trained clinicians submit data for both risk-adjusted databases. Some patient characteristics may be significantly different because of the large numbers and may not be clinically different. For example, hypertension was a comorbidity in 7399 (48.2%) of OC cases, 18,065 (45.8%) of LC cases, and 1644 (46.6%) of RC cases (P < .0001), a result that is statistically different but may not be clinically different.
Although some of the significant differences in outcomes were the same in both MSQC and ACS-NSQIP databases, there were several differences between databases for individual complications. The number of patients in the ACS-NSQIP database is much larger, and this may have resulted in higher statistical power with respect to measuring individual complications with low rates. In addition, some of the covariates that could be controlled for were not available in both databases. Finally, there is no way to elucidate surgeon decision-making, surgeon skill set, and surgeon experience for operative approaches and the impact this may have on the results of this study.
The evolution of risk-adjusted databases composed of data from surgeons of varying levels of expertise and hospitals of varying composition and demographics allowed the generation of data considered more generalizable than single-institution analyses and allowed metrics for quality improvement. Future investigations should consider risk-adjusted database limitations and which interventions may allow quality improvement in standardizing data reporting and abstraction for reliability. Application of the science of data analytics to promote standardized collection and analysis of high-quality data for the purposes of clinical research is worthy of further investigation.13
CONCLUSION
This outcomes comparison of 2 large multicenter-validated regional and national databases shows that minimally invasive LC and RC colorectal surgery are associated with significantly fewer postoperative adverse events and decreased hospital LOS compared with the OC approach. There are some outcomes inconsistencies between databases, and some results should be interpreted in context and with caution.
Contributor Information
Farwa Batool, Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA..
Stacey D. Collins, Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA..
Jeremy Albright, Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA..
Jane Ferraro, Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA..
Juan Wu, Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA..
Greta L. Krapohl, Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA..
Darrell A. Campbell, Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA..
Robert K. Cleary, Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA..
References:
- 1. Tam MS, Kaoutzanis C, Mullard AJ, et al. A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc. 2016;30:455–463. [DOI] [PubMed] [Google Scholar]
- 2. Bhama AR, Obias V, Welch KB, Vandewarker JF, Cleary RK. A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Surg Endosc. 2016;30:1576–1584. [DOI] [PubMed] [Google Scholar]
- 3. Hollis RH, Cannon JA, Singletary BA, Korb ML, Hawn MT, Heslin MJ. Understanding the value of both laparoscopic and robotic approaches compared to open approach in colorectal surgery. J Laparoendosc Adv Surg Tech A. 2016;26:850–856. [DOI] [PubMed] [Google Scholar]
- 4. Dolejs SC, Waters JA, Ceppa EP, Zarzaur BL. Laparoscopic versus robotic colectomy: a national surgical quality improvement project analysis. Surg Endosc. 2017;31:2387–2396. [DOI] [PubMed] [Google Scholar]
- 5. Zelhart M, Kaiser AM. Robotic versus laparoscopic versus open colorectal surgery: towards defining criteria to the right choice. Surg Endosc. 2018;32:24–38. [DOI] [PubMed] [Google Scholar]
- 6. Halabi WJ, Kang CY, Nguyen VQ, et al. Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes. World J Surg. 2013;37;2782–2790. [DOI] [PubMed] [Google Scholar]
- 7. Moghadamyeghaneh Z, Phelan M, Smith BR, Stamos MJ. Variations in laparoscopic colectomy utilization in the United States. Dis Colon Rectum. 2015;58:950–956. [DOI] [PubMed] [Google Scholar]
- 8. Yeo HL, Isaacs AJ, Abelson JS, et al. Comparison of open, laparoscopic, and robotic colectomies using a large national database. Dis Colon Rectum. 2016;59:535–542. [DOI] [PubMed] [Google Scholar]
- 9. Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopic assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314:1346–1355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314:1356–1363. [DOI] [PubMed] [Google Scholar]
- 11. Crawshaw BP, Chien HL, Augestad KM, Delaney CP. Effect of laparoscopic surgery on health care utilization and costs in patients who undergo colectomy. JAMA Surg. 2015;150:410–415. [DOI] [PubMed] [Google Scholar]
- 12. Wexner SD, Berho ME. The rationale for and reality of the New National Accreditation Program for Rectal Cancer. Dis Colon Rectum. 2017;60:595–602. [DOI] [PubMed] [Google Scholar]
- 13. Chang GJ. Leveraging data, the next big advance for quality improvement in colorectal cancer. Dis Colon Rectum. 2018;61:415–416. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Zawadzki M, Krzystek-Korpacka M, Rząca M, Czarnecki R, Obuszko Z, Witkiewicz W. Introduction of robotic surgery into a community hospital setting: a prospective comparison of robotic and open colorectal resection for cancer. Dig Surg. 2017;34:489–494. [DOI] [PubMed] [Google Scholar]
- 15. Murray ACA, Chiuzan C, Kiran RP. Risk of anastomotic leak after laparoscopic versus open colectomy. Surg Endosc. 2016;30:5275–5282. [DOI] [PubMed] [Google Scholar]
- 16. Rencuzogullari A, Benlice C, Valente M, Abbas MA, Remzi FH, Gorgun E. Predictors of anastomotic leak in elderly patients after colectomy: nomogram-based assessment from the American College of Surgeons National SUrgical Quality Program procedure-targeted cohort. Dis Colon Rectum. 2017;60:527–536. [DOI] [PubMed] [Google Scholar]
- 17. Kwon S, Morris A, Billingham R, et al. Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program. Arch Surg. 2012;147:345–351. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Feinberg AE, Elnahas A, Bashir S, Cleghorn MC, Quereshy FA. Comparison of robotic and laparoscopic colorectal resections with respect to 30-day perioperative morbidity. Can J Surg. 2016;59:262–267. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Baik SH, Kwon HY, Kim JS, et al. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Oncol. 2009;16:1480–1487. [DOI] [PubMed] [Google Scholar]
- 20. Scarpinata R, Aly EH. Does robotic rectal cancer surgery offer improved early postoperative outcomes. Dis Colon Rectum. 2013;56:253–262. [DOI] [PubMed] [Google Scholar]
- 21. Feroci F, Lenzi E, Garzi A, Vannucchi A, Cantafio S, Scatizzi M. Intracorporeal versus extracorporeal anastomosis after laparoscopic right hemicolectomy for cancer: a systematic review and meta-analysis. Int J Colorectal Dis. 2013;28:1177–1186. [DOI] [PubMed] [Google Scholar]
- 22. Morpurgo E, Contardo T, Molaro R, Zerbinati A, Orsini C, D'Annibale A. Robotic-assisted intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy for cancer: a case control study. J Laparoendosc Adv Surg Tech A. 2013;23:414–417. [DOI] [PubMed] [Google Scholar]
- 23. Trastulli S, Coratti A, Guarino S, et al. Robotic right colectomy with intracorporeal anastomosis compared with laparoscopic right colectomy with extracorporeal and intracorporeal anastomosis: a retrospective multicentre study. Surg Endosc. 2015;29:1512–1521. [DOI] [PubMed] [Google Scholar]
- 24. Addae JK, Gani F, Fang SY, et al. A comparison of trends in operative approach and postoperative outcomes for colorectal cancer surgery. J Surg Res. 2017;208:111–120. [DOI] [PubMed] [Google Scholar]
- 25. Barrie J, Jayne DG, Wright J, et al. Attaining surgical competency and its implications in surgical clinical trial design: a systematic review of the learning curve in laparoscopic and robotic-assisted laparoscopic colorectal cancer surgery. Ann Surg Oncol. 2014;21:829–840. [DOI] [PubMed] [Google Scholar]
- 26. Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB. Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum. 2012;55:1300–1310. [DOI] [PubMed] [Google Scholar]
- 27. Tyler JA, Fox JP, Desai MM, Perry WB, Glasgow SC. Outcomes and costs associated with robotic colectomy in the minimally invasive era. Dis Colon Rectum. 2013;56:458–466. [DOI] [PubMed] [Google Scholar]
- 28. Rawlings AL, Woodland JH, Vegunta RK, Crawford DL. Robotic versus laparoscopic colectomy. Surg Endosc. 2007;21:1701–1708. [DOI] [PubMed] [Google Scholar]
- 29. Salman M, Bell T, Martin J, Bhuva K, Grim R, Ahuja V. Use, cost, complications, and mortality of robotic versus nonrobotic general surgery procedures based on a nationwide database. Am Surg. 2013;79:553–560. [PubMed] [Google Scholar]
- 30. Cleary RK, Mullard AJ, Ferraro J, Regenbogen SE. The cost of conversion in robotic and laparoscopic colorectal surgery. Surg Endosc. 2017. September 15 DOI: 10.1007/s00464-017-5839-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Rashidi L, Neighorn C, Bastawrous A. Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system. Am J Surg. 2017;213:901–905. [DOI] [PubMed] [Google Scholar]