Elsevier

Journal of Surgical Research

Volume 208, February 2017, Pages 111-120
Journal of Surgical Research

Gastrointestinal
A comparison of trends in operative approach and postoperative outcomes for colorectal cancer surgery

https://doi.org/10.1016/j.jss.2016.09.019Get rights and content

Abstract

Background

Data-assessing trends and perioperative outcomes relative to surgical approach for colorectal cancer (CRC) surgery are lacking. We report national trends of CRC surgery and compare postoperative outcomes by surgical approach.

Methods

A total of 261,886 patients undergoing surgery for CRC were identified using the Nationwide Inpatient Sample from 2009 to 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 cost by surgical approach.

Results

At the time of surgery, 57.5% underwent an open procedure, whereas 42.4% underwent either a laparoscopic (39.9%) or robotic (2.5%) colorectal surgery. The use of minimally invasive surgery increased over time (2009 versus 2012: 37.3% versus 46.8%; P < 0.001). Postoperative morbidity was 15.9% and was higher after open surgery (open versus laparoscopic versus robotic: 18.4% versus 12.4% versus 13.3%; P < 0.001). Patients who underwent a minimally invasive surgery had shorter LOS (laparoscopic: OR, 0.55, 95% CI, 0.52-0.58; robotic: OR, 0.58; 95% CI, 0.49-0.69; both P < 0.001). Robotic surgery was consistently associated with the highest mean costs followed by laparoscopic and open surgery (P < 0.001).

Conclusions

Patients undergoing minimally invasive colorectal surgery had a lower postoperative morbidity and shorter LOS compared with patients undergoing open colorectal surgery.

Introduction

Colorectal cancer (CRC) is the third leading cause of cancer and the second leading cause of cancer-related death in the United States.1 Given improved cancer screening and recent advances in the treatment of CRC, the number of deaths per 100,000 has steadily decreased. However, it is still expected that in 2016 over 49,000 patients will die from CRC.2 Surgical resection remains the mainstay for treatment of CRC with the extent of surgery and the need for chemotherapy and radiation varying by stage and disease presentation.3, 4 Recently, there has been a shift from a traditional open colorectal resection to the adoption of minimally invasive surgical approaches such as laparoscopic, and most recently, robotic surgery. Of note, prospective single-center clinical trials have demonstrated minimally invasive surgery (MIS) to be associated with improved short-term outcomes, including a decreased length of stay (LOS), improved postoperative pain control, decreased postoperative morbidity, and lower hospital cost.5, 6

Moving to an era of greater financial accountability, there is an increasing interest to evaluate data comparing trends and outcomes relative to the method of operative approach. More specifically, as postoperative outcomes are an important determinant of hospital and physician reimbursement, data comparing postoperative clinical and financial outcomes by operative approach are critical to quality improvement efforts. Data-evaluating national trends in the use of minimally invasive versus open surgery after 2009, however, remain largely unknown. The limited number of reports assessing trends and outcomes after surgery are limited to single-center or multicenter studies and are therefore unable to report on national trends. Furthermore, to the best of our knowledge, no study has explicitly compared the use of open, laparoscopic, and robotic surgery using a nationally representative data set. Given this, the aim of the present study was to report on national trends in operative approach for the primary surgical resection of CRC. In addition, we sought to compare postoperative clinical and financial outcomes between patients who underwent either an open, laparoscopic, or robotic surgery for CRC.

Section snippets

Data source and patient population

This retrospective, cross-sectional study was performed using the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) database from January 1, 2009 to December 31, 2012. The HCUP-NIS is the largest, nationally representative, all-payer, in patient database in the United States. The NIS represents 20% of all hospital discharges and is collected from over 7 million annual hospital discharges. For each patient record, sociodemographic characteristics including age, sex,

Baseline patient and hospital characteristics

We identified 261,886 patients with colon and rectal cancer who underwent either an open (n = 150,683, 57.5%), laparoscopic (n = 104,574, 39.9%), or robotic (n = 6,629, 2.5%) bowel resection (Table 1). The median patient age was 67 y (IQR, 57-77) with a slight majority of patients being male (n = 133,940, 51.1%). Comorbidities were commonly observed with 57.6% of patients presenting with a CCI score >2 (n = 150,742). The most common payer was Medicare (n = 144,249, 55.1%) followed by private

Discussion

Evidence from previous studies suggests an increase in the incidence of laparoscopic surgery over time. For example, Kemp and Finlayson,14 in their review of patients undergoing colorectal surgery noted an increase in the use of laparoscopic surgery from 1.4% in 2000 to 4.3% in 2004. Similarly, Kang et al. in their study of patients undergoing a bowel resection reported that 11.7% were operated using a laparoscopic surgery in 2007.14, 15 Consistent with these findings, the present study

Acknowledgment

Funding: None.

Author's contributions: Study concept and design were done by J.K.A., F.G., D.M.E., and E.B.S. Analysis and interpretation of data were carried out by J.K.A., F.G., S.Y.F., E.C.W., A.A.A., J.E.E., J.K.C., D.M.E., and E.B.S. Drafting of manuscript was helped by J.K.A., F.G., D.M.E., and E.B.S. Critical revision of the manuscript for important intellectual content was done by J.K.A., F.G., S.Y.F., E.C.W., A.A.A., J.E.E., J.K.C., D.M.E., E.B.S. Final approval of the manuscript was

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    This study was presented at the 57th Annual Meeting of the Society for Surgery of the Alimentary Tract held on May 21-24, 2016, San Diego, California.

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