Defining benchmarks for robotic-assisted low anterior rectum resection in low-morbid patients: a multicenter analysis

Jan-Hendrik Egberts,Markus Hirschburger,Benno Mann,Thomas Becker,Jan-Niclas Kersebaum,Heiko Aselmann,Julia Graß,Jakob Izbicki,Daniel Perez

doi:10.1007/s00384-021-03988-6

Abstract

PurposeTo define the best possible outcomes for robotic-assisted low anterior rectum resection (RLAR) using total mesorectal excision (TME) in low-morbid patients, performed by expert robotic surgeons in German robotic centers. The benchmark values were derived from these results.MethodsThe data was retrospectively collected from five German expert centers. After patient exclusion (prior surgery, extended surgery, no prior anastomosis, hand-sewn anastomosis), the benchmark cohort was defined (n = 226). The median with interquartile range was first calculated for the individual centers. The 75th percentile of the median results was defined as the benchmark cutoff and represents the “perfect” achievable outcome. This applied to all benchmark values apart from lymph node yield, where the cutoff was defined as the 25th percentile (more lymph nodes are better).ResultsThe benchmark values for conversion and intraoperative complication rates were ≤ 4.0% and ≤ 1.4%, respectively. For postoperative complications, the benchmark was ≤ 28% for “any” and ≤ 18.0% for major complications. The R0 and complete TME rate benchmarks were both 100%, with a lymph node yield of > 18. The benchmark for rate of anastomotic insufficiency was < 12.5% and 90-day mortality was 0%. Readmission rates should not exceed 4%.ConclusionThis outcome analysis of patients with low comorbidity undergoing RLAR may serve as a reference to evaluate surgical performance in robotic rectum resection.

Highlights

Rectal resection, in addition to emerging total neoadjuvant therapy [1], is currently the common curative therapy for localized rectal carcinoma [2]
A metaanalysis published by Han et al in 2020, which compared the perioperative outcomes of limitations of conventional laparoscopy (LLAR) and RLAR from eight randomized controlled trial (RCT) involving 999 patients, showed that while RLAR led to significantly longer operative time, the conversion rate was lower [4]
Our study aims to evaluate the perioperative outcomes of RLAR after completion of the learning curve in an ideal cohort of patients, and establish the first benchmark values worldwide that can be used as a comparison for other centers or even other techniques

Summary

Introduction

In addition to emerging total neoadjuvant therapy [1], is currently the common curative therapy for localized rectal carcinoma [2]. Robotic-assisted low anterior rectum resection (RLAR) can overcome many known limitations of conventional laparoscopy (LLAR). The feasibility and safety of RLAR are well established, and there is growing evidence that it may offer better peri- and postoperative outcomes compared to LLAR [3]. A metaanalysis published by Han et al in 2020, which compared the perioperative outcomes of LLAR and RLAR from eight RCTs involving 999 patients, showed that while RLAR led to significantly longer operative time, the conversion rate was lower [4]. Most of the available literature consists of retrospectively collected datasets, including patients who are operated within the surgeon’s learning curve for RLAR to increase the cohort.

Methods

Results

Conclusion