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Trends and Short-Term Outcomes of Surgical Methods for Bowel Resection In Colorectal Cancer Patients
Jamin K. Addae*1, Faiz Gani1, Joseph K. Canner1, Sandy Fang1, ERIC B. SCHNEIDER2
1Surgery, Johns Hopkins University School of medicine, Baltimore, MD; 2Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
Background: Current trends regarding surgical approach for colorectal cancer surgery remain undetermined. Additionally, national data comparing postoperative clinical outcomes relative to cost for open vs. laparoscopic vs. robotic approaches is lacking. We sought to report on national trends of colorectal cancer surgery as well as compare postoperative outcomes by surgical approach.
Methods: Patients undergoing surgery for colorectal cancer were identified using the Nationwide Inpatient Sample from January 1, 2009 to December 31, 2012. Trends in surgical approach were assessed using the Cochrane-Armitage test of trends. Multivariable logistic and linear regression analyses were performed to compare length-of-stay (LOS), postoperative complications and costs between open and MIS surgery.
Results: A total of 261,886 patients were identified. The median age of the cohort was 67 years (IQR 19-104) while 51.1% (n=133,940) were male. 72.2% (n=188,989) of patients underwent a colon surgery while 27.8% (n=72,897) underwent a rectal procedure. At the time of surgery, 57.5% (n=150,683) underwent an open procedure, while 42.4% (n=111,203) underwent either a laparoscopic (39.9%, n=104,574) or robotic (2.5%, n=6,629) colorectal surgery. Overtime, the use of MIS was noted to increase with an almost four-fold increase in the use of a robotic approach (2009 vs. 2012: 1.1% [n=714] vs. 4.2% [n=2740]; p<0.001). In contrast, while 62.7% (n=40,631) of colorectal surgery performed in 2009 was via an open approach, only 53.2% (n=34,505) of those performed in 2012 was via an open approach (p<0.001). Postoperative morbidity was 15.9% and was higher among patients who underwent open surgery compared with patients who underwent a MIS surgery (18.4% vs. 12.4%, p<0.001; OR 1.43, 95%CI 1.35-1.51; p<0.001). Of note, among patients who underwent MIS, patients those who had robotic surgery were more likely to develop surgical site infections compared to patients who underwent laparoscopic surgery (3.6% vs. 2.6%, p=0.024). Similarly, patients who underwent MIS surgery had shorter LOS compared to patients undergoing open surgery (extended LOS [LOS>8 days]: laparoscopic: OR 0.55, 95%CI 0.52-0.58, robotic: OR 0.58, 95%CI 0.49-0.69; both p<0.001). While the costs of surgery remained constant over time (all p>0.05), robotic surgery was consistently associated with a highest mean cost; however, costs were comparable between laparoscopic and open surgery (p>0.05).
Conclusion: Minimally invasive colorectal surgery is increasingly being performed. Patients undergoing MIS colorectal surgery had a lower postoperative morbidity and shorter LOS compared with patients undergoing open colorectal surgery.
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