Hand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort

doi:10.1016/j.amjsurg.2016.02.014

The American Journal of Surgery

Volume 212, Issue 5, November 2016, Pages 808-813

The study was presented as a “poster presentation” at the Society of American Gastrointestinal and Endoscopic Surgeons Annual Meeting, April 15–18, 2015, Nashville, TN, USA.

https://doi.org/10.1016/j.amjsurg.2016.02.014 Get rights and content

Highlights

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Outcomes of HALS and open colectomy were compared using procedure-targeted database.
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NSQIP data demonstrated several advantages of HALS compared with open colectomy.
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Elective HALS colectomy maintains advantages of straight laparoscopy over open.
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HALS provides additional benefit over open surgery for complex colorectal diseases.
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Our study supports benefits of HALS as initial approach or bridge to laparoscopy.

Abstract

Background

Perioperative outcomes of patients who underwent hand-assisted colorectal laparoscopic (HALS) vs open colectomy were compared using recently released procedure-targeted database.

Methods

Review was conducted using the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. Patients were classified into 2 groups according to final surgical approach: HALS vs open (planned). Groups were matched (1:1) based on age, gender, body mass index, surgical procedure, diagnosis, American Society of Anesthesiologists score, and wound classification. Multivariate logistic regression analysis was conducted for group comparison.

Results

Of 7,303 patients, 1,740 patients were matched in each group. Open group had higher proportion of patients with preoperative dyspnea (P = .01), ascites (P = .01), weight loss (P < .001), smoking history (P = .04), and increased work relative value units (P < .001). After adjusting for difference in baseline comorbidities, overall morbidity, superficial, deep, and organ-space surgical site infection, urinary tract infection, ileus, reoperation, readmission, and hospital stay were significantly higher in open group (P < .05).

Conclusions

National Surgical Quality Improvement Program targeted-data demonstrated several advantages of HALS compared with open colonic resection including shorter hospital stay and lower complication rate. Further adoption of HALS technique as a bridge to straight laparoscopy or tool in difficult cases can positively impact the short-term outcomes after colectomy when compared with open technique.

Section snippets

Data collection

The 2012 ACS-NSQIP colectomy-targeted participant user file contains information about 22 procedure-specific variables in addition to generalized multispecialty ACS-NSQIP database from 121 different centers within the United States. These specific colectomy-related variables include details about preoperative assessment, operative information, and postoperative complications.¹⁰ Additional information for each patient was obtained by merging the unique case identifier variable in the

Results

During the study period, 7,303 patients were identified; 3,038 patients in the HALS, and 4,265 in the open groups. Fig. 1 demonstrates the distribution of diagnoses before matching. The most frequent reason for surgery in the HALS group was colon cancer followed by diverticular disease (Fig. 1).

After case matching, there were 1,740 patients in each group. Table 1 displays the matching criteria between the 2 groups. Preoperative characteristics and demographics were comparable between the groups

Comments

HALS is an established alternative to the straight laparoscopic approach and is currently used in colorectal surgery.11, 12 Several studies have advocated the use of HALS to minimize the need for conversion to open and to decrease operative time in complex cases.6, 13, 14, 15 However, there is a paucity of data on the advantages of HALS compared with the open technique. The present study presents the first direct comparison of HALS and open technique in patients undergoing elective colectomy

Acknowledgments

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

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The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach.
A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications.
Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients.
The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis.
Sustained positive impact of ACS-NSQIP program on outcomes after colorectal surgery over the last decade
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Citation Excerpt :
The procedure-targeted datasets allow detailed exploration of specific operative characteristics and outcomes parameters. In fact, several studies10–13 have influenced current colorectal surgery practice using colectomy-targeted information.14 However, it is unknown whether the introduction of colectomy-specific data has improved the colorectal surgery outcomes for the participating hospitals.
We evaluate trends in outcomes after colorectal resection over the decade of the introduction of ACS-NSQIP as well as of targeted-colectomy information.
From 2007 to 2016, patients undergoing non-emergent colorectal procedures were included. Demographics, operative complexity (American Society of Anesthesiologists and wound classes); complications, early (<5 days) discharge and mortality were plotted over years. Outcomes after introduction of colectomy-targeted datasets (2013–2016) were compared to those prior (2007–2012). Multivariable analyses were performed to evaluate the impact of colectomy-targeted data on outcomes.
Of 310,632 included procedures, 131,122(42.2%) and 179,510(57.8%) were performed before and after the introduction of colectomy-targeted variables respectively. Most complications including surgical site and urinary tract infections, sepsis, septic shock, venous thromboembolism, respiratory complications, reoperation and mortality reduced over time with increased early discharge. On multivariable analysis, introduction of colectomy-targeted data was associated with lower surgical site (OR = 0.78,95%CI = [0.77–0.80]); systemic (OR = 0.94,95%CI = [0.91–0.98]) and urinary tract (OR = 0.70,95%CI = [0.67–0.74]) infections; reoperation (OR = 0.88,95%CI = [0.85–0.91]) and early discharge (OR = 1.60,95%CI = [1.57–1.63]).
Over its first decade of introduction, ACS-NSQIP has been associated with improved outcomes after colorectal surgery. The introduction of colectomy-targeted data has further improved outcomes.
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The HALS patients had lower rates of wound infections, earlier tolerance of oral diet, and decreased LOS, which arguably justified the increased operative time. In a much larger case-matched review using the National Surgical Quality Improvement Program database, Benlice and colleagues23 demonstrated that HALS patients had decreased overall morbidity, surgical site infections, urinary tract infections, ileus, reoperations, readmissions, and LOS in comparison with open surgical patients. This was noted after adjusting for baseline conditions, because the open surgical patients were demonstrably sicker.
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: There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.

: The authors declare no conflicts of interest.

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Clinical ScienceHand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort

Highlights

Abstract

Background

Methods

Results

Conclusions

Section snippets

Data collection

Results

Comments

Acknowledgments

Lancet

J Am Coll Surg

J Gastrointest Surg

J Am Coll Surg

J Am Coll Surg

Surgery

Am J Surg

Am J Surg

Minimally invasive colon resection (laparoscopic colectomy)

Surg Laparosc Endosc

Laparoscopic colon resection early in the learning curve: what is the appropriate setting?

Ann Surg

Hand-assisted laparoscopic sigmoid colectomy: helping hand or hindrance?

Surg Endosc

The controversy regarding hand-assisted colorectal resection

Surg Endosc

Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial

Ann Surg

Clinical Science
Hand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort