Comparative analysis of surgical inflammatory response with C-reactive protein post robotic versus laparoscopic elective colorectal resection for colorectal tumour

Aims Determining factors affecting the WCC and CRP in laparoscopic and robotic colorectal cancer resections within the immediate 48-hour period. Methods Single centre data was collected retrospectively.100 robotic and 193 laparoscopic cases were included. Cut offs for WCC and CRP were set at >11 and >50. Fisher's Exact test was used for analysis. Results Robotic group had 67% left sided operations vs 43% laparoscopically. Stoma formation was higher in the robotic group (61% Vs 15%). Other patient demographics including male to female ratio, BMI, ASA and tumour size were comparable. Average length of stays (LOS) and operation times were longer for robotic than laparoscopic approaches of the same operation. Average lymph node yield was higher for robotic right hemicolectomy 26.6 (vs 23.5 laparoscopic) (P=0.05). Median WCC within 48-hours was higher in the laparoscopic group 10.9 (vs 11.3 robotic). More laparoscopic cases 53% (vs 35% robotic) had WCC >11 (P=0.006). Median 48h CRP was higher in robotic 51.6 (vs 45.6 laparoscopic). CRP was consistently higher in operations involving stoma formation (P= 0.008) and operative time >4 hours (P=0.001) both laparoscopically and robotically. Conclusions Absolute median immediate WCC and CRP were similar between laparoscopic and robotic colorectal resections although operative times were longer and stoma formation higher in the robotic group. Stoma formation and longer operations correlated with higher CRPs. No firm conclusions can be drawn about differences in the immediate serum WCC and CRP between laparoscopic and robotic cases in this study due to confounding factors.

A variety of approaches are available for division of major vascular structures during laparoscopic colorectal resection. Ultrasonic coagulating shears (UCS), vascular staplers, plastic or titanium clips and electrothermal bipolar vessel sealing (EBVS) are currently available. We report our experience with an EBVS device, LigaSure™ (Covidien AG), used in division of the ileocolic, middle colic and inferior mesenteric arteries during laparoscopic colorectal resection. We report the immediate outcome of 802 consecutive unselected patients who underwent elective laparoscopic colorectal cancer resection performed with use of the LigaSure™ (5 and 10 mm) at our institution over a 5-year period. Operative procedures included right hemicolectomy (n = 180), left hemicolectomy (n = 96), sigmoid colectomy (n = 347) and anterior resection (n = 179). Data were collected from a prospectively maintained cancer database and operative records. The procedures were performed primarily by three consultant surgeons with an interest in laparoscopic colorectal resection. Of 802 cases in which the LigaSure™ device was employed to divide major vascular structures, immediate effective vessel sealing was achieved in 99.8% (n = 800). Two patients experienced related adverse events both following division of the inferior mesenteric artery with a 5 mm LigaSure™. Both patients had immediate uncontrolled haemorrhage that required laparotomy. Use of the LigaSure™ device to seal and divide the major mesenteric vessels during laparoscopic colorectal resection is very effective, with a high success rate of 99.8%. Caution should be exercised in elderly atherosclerotic patients, particularly when using the 5-mm LigaSure™ device.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

Combined laparoscopic colorectal and liver resection for patients with synchronous liver metastases of colorectal origin: a retrospective, multicenter, propensity score matched study

The purpose of this study was to develop an instrument to measure the perceived benefits nurses observe in the recovery of patients who have undergone elective laparoscopic colorectal resections vs. traditional open elective colorectal resections. Secondly, to determine if there are perceived differences in the intensity of nursing required to care for these patients. A twenty-three-point questionnaire was developed and distributed to 23 colorectal nurses working in a single tertiary referral hospital. There was an 83.6% response rate. The findings demonstrate that the participants believe there are significantly better outcomes for the laparoscopic patients in the postoperative period. These benefits include more rapid resumption of independence, decreased pain and fewer complications. The nurses also perceived less time and effort was required when caring for these patients.

We aim to describe our centre's one-year experience after establishing our robotic programme for colorectal surgery. Demographic, peri-operative, and follow-up data from a prospectively maintained database were collected for all laparoscopic and robotic-assisted colorectal procedures carried out at our centre. All robotic colorectal resections were completed with the DaVinci Xi (Intuitive Surgical, USA) robotic platform. Fifty-eight robotic colorectal resections were compared to 58 from the laparoscopic cohort, all indicated for malignancy. No statistical difference was observed between the demographics of the two cohorts regarding sex, age, body mass index (BMI), and American Society of Anesthesiologists (ASA) grade. 33/58 (56.9%) robotic resections were left-sided compared to 36/58 (62.1%) laparoscopic resections. One robotic case was converted to open (1.7%), with four (6.9%) in the laparoscopic group converted to open. Laparoscopic procedures were shorter (median operative time 282min compared to 384min, p<0.001, Wilcoxon rank-sum). Subgroup analysis for patients with ASA grades 1&2 showed shorter operative times in the laparoscopic cohort compared to the robotic cohort (p=0.003, Wilcoxon rank-sum). The median length of stay was five days for both cohorts. Significant postoperative complications (Clavien-Dindo ≥3) occurred in 3.45% (n=2/58) vs. 10.3% (n=6/58), which was not significantly different statistically. No mortalities were recorded within 90 days of the procedures in both cohorts, but at one-year follow-up, we observed one mortality in each cohort. Other than longer operative times for ASA grades 1/2 patients, robotic colorectal resection outcomes in a small district hospital setting are comparable to laparoscopic resections.

Laparoscopic colorectal surgery has been reported to have some advantages compared with open surgery. The purpose of this study was to evaluate the incidence of incisional hernias after elective open colorectal resection versus laparoscopic colorectal resection. The study group consisted of 104 patients who underwent elective colorectal resection or reversal of a Hartmann's procedure between November 2003 and March 2005. Baseline data were prospectively recorded on all patients. All were examined by an independent observer for evidence of incisional hernia after they had reached a minimum follow up of one year. At a median follow up of 22 (17-26) months, nine patients had died and 95 were reviewed. Of these, 32 underwent laparoscopic resection while 63 had open surgery. Patients were well matched for all baseline characteristics. The median length of the wound in the laparoscopic group was 9 cm (IQR: 8-11 cm) while in the open group it was 20.8 cm (IQR: 17-24 cm). There was no significant difference in incisional hernia rates between the groups (3 vs. 10, p = 0.52) or in those who had symptoms from their hernia (p = 0.773). Laparoscopic colorectal resection does not appear to reduce incisional hernia rates when compared with open surgery. Large randomised trials are required to confirm these findings.

While robotic and laparoscopic surgeries are both minimally invasive in nature, they are intrinsically different approaches and it is critical to understand outcome differences between the two. Studies evaluating pain outcomes and opioid requirement differences between the robotic and laparoscopic colorectal resections are conflicting and often underpowered. In this retrospective, cohort study, we compare postoperative opioid requirements, reported as morphine milligram equivalents (MME), postoperative average and highest pain scores across postoperative days (POD) 0-5, and return to work in patients who underwent robotic versus laparoscopic colorectal resections. The sample size was selected based on power calculations. Daily pain scores and MME were used as outcomes in linear mixed effect models with unstructured covariance between time points. Propensity score weighting was used to adjust for imbalances. Patients in the robotic group required significantly less opioids as measured by MME on all postoperative days (p = 0.004), as well as lower average and highest daily pain scores for POD 0-5 (p = 0.02, and p = 0.006, respectively). In a linear mixed-effects model, robotic resections were associated with a decrease in average pain scores by 0.36 over time (p = 0.03) and 35 fewer MME requirements than the laparoscopic group (p = 0.0004). Patients in the robotic arm had earlier return to work (2.1 vs 3.8days, p = 0.036). The robotic approach to colorectal resections is associated with significantly less postoperative pain, decreased opioid requirements, and earlier return to work when compared to laparoscopy, suggesting that the robotic platform provides important clinical advantages overthe laparoscopic approach.

Proponents suggest that laparoscopic colorectal resection might be achievable in up to 90% of cases, while keeping conversion rates below 10%. This unselected prospective case series reports on the proportion of patients having a completed laparoscopic colorectal resection in two units where laparoscopic colorectal practice is well established and readily available. All patients undergoing elective and emergency colorectal resection during a 6-month period were identified. The underlying pathology and the surgical approach (laparoscopic or open) were recorded. The contraindications to laparoscopic resection were also documented. The need and rationale for conversion to an open approach were recorded. In total, 205 consecutive patients (160 elective and 45 emergency procedures) underwent colorectal resection for malignancy [117 (57%) patients] and benign pathology [88 (43%) patients]. Laparoscopic resection was attempted in 127/205 (62%) patients and 31/127 (24%) of these were converted to open surgery. The main reasons for not attempting laparoscopic resection were locally advanced disease and emergency surgery. The commonest reasons for conversion were advanced disease and to allow completion of rectal dissection and/or cross-stapling of the rectum. Despite a special interest in laparoscopic colorectal surgery of the two colorectal units who provided the data for this study, fewer than half (96/205; 47%) of the patients in this consecutive unselected series who were undergoing major colorectal resection had the procedure completed laparoscopically.

This study was designed to evaluate the outcomes of laparoscopic colorectal resection in a period of learning curve completed by surgeons with different experience and aptitudes with a view to making clear whether seniors had a better learning curve compared with juniors. From May 2010 to August 2012, the first twenty patients underwent laparoscopic colorectal resection completed by each surgeon were selected for analysis retrospectively. A total of 240 patients treated by 5 seniors and 7 juniors were divided into the senior group (n=100) and the junior group (n=140). The short-term outcomes of laparoscopic surgery of the two groups were compared. The mean numbers of lymph nodes harvested were 21.2 ± 11.0 in the senior group and 17.3 ± 11.5 in the junior group (p=0.010); The mean operative times were 187.9 ± 60.0 min as compared to 231.3 ± 55.7 min (p=0.006), and blood loss values were 177.0 ± 100.7 ml and 234.0 ± 185 ml, respectively (p=0.001); Conversion rate in the senior group was obviously lower than in the junior group (10.0% vs 20.7%, p=0.027) and the mean time to passing of first flatus were 3.3 ± 0.9 and 3.8 ± 0.9 days (p=0.001). For low rectal cancer, the sphincter preserving rates were 68.7% and 35.3% (p=0.027). Seniors could perform laparoscopic colorectal resection with relatively better oncological outcomes and quicker recovery, and seniors could master the laparoscopic skill more easily and quickly. Seniors had a better learning curve for laparoscopic colorectal cancer resection compared to juniors.

This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection. All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission. There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002-2003 and 2007-2008. In 2002-2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007-2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85-0.91), p < 0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04-1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04-1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission. Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome. This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.

Although laparoscopic colorectal resection and laparoscopic liver resection have been accepted as effective alternatives to conventional open procedures, there are only a few reports on the clinical availability of simultaneous performance of these two procedures. We report our collective experience of patients with colorectal cancers treated with totally laparoscopic colorectal and liver resection, in comparison with those treated with an open approach. This study is a retrospective, case-match review of prospectively collected data. Between May 2008 and December 2012, 24 patients with primary colorectal cancer and associated hepatic lesions underwent simultaneous laparoscopic colorectal and liver resection (laparoscopic group). They were matched with patients who underwent an open procedure (open group; n=24 out of 232) based on the types of surgery. Patient demographics, operative details, tumor-related parameters, and postoperative outcomes were analyzed. Demographic features and pathologic outcomes were similar in both groups. The median duration of operation was significantly longer in the laparoscopic group than in the open group (290 versus 244 minutes; P=.008), and the median estimated blood loss was larger (325 versus 250 mL; difference not significant, P=.35). However, the time to starting a soft blended diet (3.0 versus 4.5 days; P<.001) and postoperative stay (8.0 versus 10.5 days; P=.001) in the laparoscopic group were both significantly shorter than in the open group. The postoperative complication rate was lower in the laparoscopic group (17% versus 42%; difference not significant, P=.06). The minor complication rate was significantly lower in the laparoscopic group (4% versus 33%; P=.02). A totally laparoscopic approach might provide short-term benefits associated with enhanced postoperative recovery despite a longer procedure time and larger blood loss. It can be a reasonable option for simultaneous colorectal and hepatic resection.

To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures. All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate. In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients. Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.

Laparoscopic liver resection for metastatic colorectal cancer (CRC) remains controversial. The objective of this study was to compare the short-term and mid-term outcomes of patients with CRC undergoing laparoscopic versus open colorectal resection with simultaneous resection for liver metastases. A total of 126 patients underwent combined laparoscopic resection of CRC and synchronous colorectal liver metastases between 2008 and 2016. A total of 318 patients were treated by an open approach during the above period. By propensity score matching, 109 patients who underwent laparoscopic resection and 109 patients who had an open approach were compared. Analyzed variables included patient characteristics, tumor features, and short-term and mid-term outcomes. Demographic features and pathologic outcomes were similar in both groups after propensity score matching. Three (2.8%) patients undergoing laparoscopic liver resection experienced conversion to open procedure. There was no difference in hospital stay (p = 0.078), transfusion rate (p = 0.686), or time of bowel function return (p = 0.570) between the two groups. The laparoscopic group and the open approach group also showed similar 3-year overall survival rate (74.4% vs. 79.1%; p = 0.792) and 3-year disease-free survival rate (58.5% vs. 55.2%; p = 0.391). However, postoperative morbidity rate was significantly lower in the laparoscopic group (20.2% vs. 33.0%; p = 0.032). Laparoscopic colorectal resection with simultaneous resection of liver metastases showed satisfactory oncologic outcomes with some short-term advantages compared to the open approach. Thus, laparoscopic approach could be a good alternative of open approach for simultaneous liver and colon resection in patients with CRC.

The role of laparoscopic colorectal resection for patients undergoing a simultaneous operation for liver metastases had not been established. This study compared the outcomes between laparoscopic and open colorectal resections for patients undergoing simultaneous surgery for liver metastases. This study reviewed 40 consecutive patients undergoing simultaneous R0 resection of synchronous liver metastases between January 2003 and August 2008. In the study, 20 patients who underwent laparoscopic colorectal resection were matched with 20 patients who had an open approach. All available clinicopathologic variables possibly associated with outcome were compared. The laparoscopic and open groups had similar demographics. No patient undergoing the laparoscopic procedure experienced conversion to the open technique. No postoperative mortality occurred in either group. The estimated blood loss was significantly lower in the laparoscopic group than in the open group. Although the operating time in the laparoscopic group was significantly longer (358 vs. 278 min; p = 0.004), the patients in this group had bowel function return 1 day sooner on the average than those in the open group. No significant differences in postoperative complications were observed between the groups. The overall survival was 58.7% at 3 years and 49.2% at 5 years. The 3-year overall survival rate in the laparoscopic group was not significantly different from that in the open group (52.8 vs. 61.0%; p = 0.713). Laparoscopic colorectal resection with simultaneous resection of liver metastases has an outcome similar to that for an open approach but some short-term advantages.