Minimally Invasive Surgery Is Underutilized for Colon Cancer

Background

The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication.

Methods

The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ² tests and dependent t tests, and Cramer’s V was used to measure the strength of association.

Results

A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers.

Conclusions

Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.     

Disc Space Preparation in Transforaminal Lumbar Interbody Fusion: A Comparison of Minimally Invasive and Open Approaches

Background

Minimally invasive surgical (MIS) approaches to transforaminal lumbar interbody fusion (TLIF) have been developed as an alternative to the open approach. However, concerns remain regarding the adequacy of disc space preparation that can be achieved through a minimally invasive approach to TLIF.

Questions/purposes

The purpose of this cadaver study is to compare the adequacy of disc space preparation through MIS and open approaches to TLIF. Specifically we sought to compare the two approaches with respect to (1) the time required to perform a discectomy and the number of endplate violations; (2) the percentage of disc removed; and (3) the anatomic location where residual disc would remain after discectomy.

Methods

Forty lumbar levels (ie, L1-2 to L5-S1 in eight fresh cadaver specimens) were randomly assigned to open and MIS groups. Both surgeons were fellowship-trained spine surgeons proficient in the assigned approach used. Time required for discectomy, endplate violations, and percentage of disc removed by volume and mass were recorded for each level. A digital imaging software program (ImageJ; US National Institutes of Health, Bethesda, MD, USA) was used to measure the percent disc removed by area for the total disc and for each quadrant of the endplate.

Results

The open approach was associated with a shorter discectomy time (9 versus 12 minutes, p = 0.01) and fewer endplate violations (one versus three, p = 0.04) when compared with an MIS approach, percent disc removed by volume (80% versus 77%, p = 0.41), percent disc removed by mass (77% versus 75%, p = 0.55), and percent total disc removed by area (73% versus 71%, p = 0.63) between the open and MIS approaches, respectively. The posterior contralateral quadrant was associated with the lowest percent of disc removed compared with the other three quadrants in both open and MIS groups (50% and 60%, respectively).

Conclusions

When performed by a surgeon experienced with MIS TLIF, MIS and open approaches are similar in regard to the adequacy of disc space preparation. The least amount of disc by percentage is removed from the posterior contralateral quadrant regardless of the approach; surgeons should pay particular attention to this anatomic location during the discectomy portion of the procedure to minimize the likelihood of pseudarthrosis.     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Prospective study of physical activity and quality of life in Japanese women undergoing total hip arthroplasty

Background

Improvement in quality of life (QoL) in patients who went through total hip arthroplasty (THA) is well studied, while the number of studies on improvement in actual daily activity in THA patients is limited. The purpose of the study was (1) to describe the pre- to postoperative changes in physical activity (PA) levels, (2) compare PA levels with healthy controls, and (3) examine the association between PA levels and QoL in Japanese women undergoing THA.

Methods

PA was measured by pedometers, and QoL was assessed by the Short-Form 8 and the Oxford Hip Scale questionnaires. Consecutive patients undergoing primary THA at Saga University Hospital, Japan, in 2008 were eligible for the study. QoL and pedometers with accelerometers were mailed to THA patients 1 month pre-THA and 6 and 12 months post-THA. The control group completed a single assessment of questionnaires and pedometers.

Results

Thirty-eight THA patients completed the study. Preoperatively, the patient group had significantly lower QoL scores than the comparison group. However, these differences disappeared by 12 months post-THA. When improvement of PA function in THA patients was compared with healthy controls, light PA was already 78 % of the healthy controls at the pre-THA period and improved to 90 % at 12 months. In contrast, moderate PA was 27 % of the controls and rose to 77 % by 12 months, and vigorous PA remained low throughout the study period. PA was correlated with QoL scores.

Conclusion

The study shows the relative recovery process of PA indicators in THA patients and the contribution of PA to the improvement of QoL.     

Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial plateau fractures: a clinical computed tomography-based measurement and the associated biomechanical model simulation

Objectives

The aim of our study is to evaluate the incidence and pathoanatomy of posterolateral fragments and analyze the associated fracture mechanism in bicondylar tibial plateau fractures.

Methods

From 1.1.2008 to 3.15.2012, all patients suffering bicondylar tibial plateau fractures were identified, scanned and analyzed at the Shanghai Clinical Trauma Center. Furthermore cadaver knees were selected into three groups of 30/60/90 knee flexion to simulate the posterolateral tibial plateau fracture by an impact device.

Results

One hundred and sixty-four (44.32 %) bicondylar tibial plateau fractures finally satisfied our requirements. Fifty-three and ninety-four cases were measured eventually in the groups of posterolateral split and depression. The posterolateral articular fragment proportion was 15.43 %. The posterolateral articular fragment angle showed an average of 12.94°. The posterolateral fragment cortical height was on average 2.96 cm. The posterolateral sagittal fragment angle averaged at 72.06°. Ninety-four cases were measured in the posterolateral depression group. The average posterolateral articular depression proportion was 16.74 %. The average posterolateral articular depression height was 2.47 cm. In the biomechanical modeling of such kinds of fracture patterns, posterolateral split fractures in 30° and 60° flexion are significantly more than those in 90° flexion. Posterolateral splits combined with anterolateral depression fractures in 30° flexion are significantly more than those in 90° flexion.

Conclusion

The incidence of posterolateral fractures is 44.32 % in bicondylar tibial plateau fractures. The morphology of posterolateral area can be referenced for the surgeon in the future clinical work. The information is also helpful for the design of locking plate and fracture modeling in biomechanical test. In addition, that posterolateral split and posterolateral depression might be caused by different injury mechanisms. Different angles of knee flexion under the axial impact loading are possibly the interpretations for these two fracture patterns.     

Laparoscopic Appendectomy: Minimally Invasive Surgery Training Improves Outcomes in Basic Laparoscopic Procedures

Background

To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training.

Methods

Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded.

Results

A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32–60 vs. 58 min, IQR 44–81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001).

Conclusions

MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.

     

National Trends in Postoperative Outcomes and Cost Comparing Minimally Invasive Versus Open Liver and Pancreatic Surgery

Background

Although minimally invasive surgery (MIS) has been associated with improved postoperative clinical outcomes, the widespread use of MIS by procedure and hospital has been limited. We sought to report on national trends postoperative clinical outcomes for minimally invasive liver and pancreatic surgery.

Methods

Patients undergoing an elective liver or pancreatic resection were identified using the Nationwide Inpatient Sample between 2002 and 2012. Multivariable regression analysis was used to compare postoperative outcomes, and total hospital costs between patients who underwent a MIS versus an open resection over the study time period.

Results

A total of 47,685 patients were identified; 21,280 (44.6 %) patients underwent a hepatic resection while 26,405(55.4 %) patients underwent a pancreatic resection. MIS was performed in 2674 (5.6 %) patients and increased from 2.6 % in 2002 to 9.6 % in 2012 (p?<?0.001); this trend was observed for both pancreatic and liver resections (both p?<?0.001). Over the study time period, use of MIS was consistently associated with improved postoperative outcomes including decreased postoperative morbidity (open vs. MIS: 32.9 vs. 29.6 %) and a shorter length-of-stay (≤4 days; MIS, 21.4 %; Open, 13.7 %; both p?<?0.05). The median costs associated with MIS decreased over time compared with the open surgical approach and were on average $572 lower than the cost associated with open surgery.

Conclusion

Compared to open resection, MIS was associated with lower postoperative morbidity, a shorter length-of-stay, and lower cost. The use of MIS should be encouraged in order to improve postoperative outcomes and decrease healthcare spending via value enhancement.

     

Minimally Invasive Technique Leads to Decreased Morbidity and Mortality in Small Bowel Resections Compared to an Open Technique: An ACS-NSQIP Identified Target for Improvement

Background

We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection.

Methods

Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent a small bowel resection between 2007 and 2011 were enrolled in the study and grouped whether they received a MIS procedure (n?=?1,780) or an OP procedure (n?=?17,701). The primary endpoint of the study was to evaluate the difference in morbidity (excluding mortality) and mortality in patients undergoing a minimally invasive procedure compared to an open procedure.

Results

The MIS technique is utilized in 9.0 % of patients undergoing a small bowel resection. Significantly lower mortality rate (2.9 vs. 8.2 %; p?<?0.001) and mean morbidity rate (1.7 vs. 4.3 %; p?<?0.001) were demonstrated in the MIS group. Significantly lower mean major morbidity rate (1.4 vs. 3.9 %; p?<?0.001) and mean minor morbidity rate (2.6 vs. 5.5 %; p?<?0.001) were demonstrated in the MIS group.

Conclusion

The MIS technique in small bowel resections appears to be underutilized, with only 9.0 % of patients in need of a small bowel resection undergo the minimally invasive approach. Wider utilization of the MIS technique could lead to significantly decreased morbidity and mortality.     

Pelvic Tilt Is Minimally Changed by Total Hip Arthroplasty

Background

While surgical navigation offers the opportunity to accurately place an acetabular component, questions remain as to the best goal for acetabular component positioning in individual patients. Overall functional orientation of the pelvis after surgery is one of the most important variables for the surgeon to consider when determining the proper goal for acetabular component orientation.

Questions/Purposes

We measured the variation in pelvic tilt in 30 patients before THA and the effect of THA on pelvic tilt in the same patients more than a year after THA.

Methods

Each patient had a CT study for CT-based surgical navigation and standing and supine radiographs before and after surgery. Pelvic tilt was calculated for each of the radiographs using a novel and validated two-dimensional/three-dimensional matching technique.

Results

Mean supine pelvic tilt changed less than 2°, from 4.4° ± 6.4° (range, ?7.7° to 20.8°) before THA to 6.3° ± 6.6° (range, ?5.7° to 19.6°) after THA. Mean standing pelvic tilt changed less than 1°, from 1.5° ± 7.2° (range, ?13.1° to 12.8°) before THA to 2.0° ± 8.3° (range, ?12.3° to 16.8°) after THA. Preoperative pelvic tilt correlated with postoperative tilt in both the supine (r² = 0.75) and standing (r² = 0.87) positions.

Conclusions

In this population, pelvic tilt had a small and predictable change after surgery. However, intersubject variability of pelvic tilt was high, suggesting preoperative pelvic tilt should be considered when determining desired acetabular component positioning on a patient-specific basis.     

Comparison of Midterm Outcomes of Minimally Invasive Computer-Assisted vs Minimally Invasive Jig-Based Total Knee Arthroplasty

Background

Minimally invasive surgery (MIS) has perceived advantages in the early postoperative stage for total knee arthroplasty (TKA). It is not clear whether the improved radiographic alignment achieved by computer-assisted navigation surgery (CAS) improves midterm clinical outcomes. The aim of this study was to compare patient outcomes of MIS TKA performed with and without CAS after a minimum follow-up of 7 years.

Minimally Invasive Surgical Techniques in Adult Degenerative Spinal Deformity: A Systematic Review

Background

Minimally invasive surgery (MIS) approaches have the potential to reduce procedure-related morbidity when compared with traditional approaches. However, the magnitude of radiographic correction and degree of clinical improvement with MIS techniques for adult spinal deformity remain undefined.

Question/purposes

In this systematic review, we sought to determine whether MIS approaches to adult spinal deformity correction (1) improve pain and function; (2) reliably correct deformity and result in fusion; and (3) are safe with respect to surgical and medical complications.

Methods

A systematic review of PubMed and Medline databases was performed for published articles from 1950 to August 2013. A total of 1053 papers were identified. Thirteen papers were selected based on prespecified criteria, including a total of 262 patients. Studies with limited short-term followup (mean, 12.1 months; range, 1.5–39 months) were included to capture early complications. All of the papers included in the review constituted Level IV evidence. Patient age ranged from 20 to 86 years with a mean of 65.8 years. Inclusion and exclusion criteria were variable, but all required at minimum a diagnosis of adult degenerative scoliosis.

Results

Four studies demonstrated improvement in leg/back visual analog scale, three demonstrated improvement in the Oswestry Disability Index, one demonstrated improvement in treatment intensity scale, and one improvement in SF-36. Reported fusion rates ranged from 71.4% to 100% 1 year postoperatively, but only two of 13 papers relied consistently on CT scan to assess fusion, and, interestingly, only four of 10 studies reporting radiographic results on deformity correction found the procedures effective in correcting deformity. There were 115 complications reported among the 258 patients (46%), including 37 neurological complications (14%).

Conclusions

The literature on these techniques is scanty; only two of the 13 studies that met inclusion criteria were considered high quality; CT scans were not generally used to evaluate fusion, deformity correction was inconsistent, and complication rates were high. Future directions for analysis must include comparative trials, longer-term followup, and consistent use of CT scans to assess for fusion to determine the role of MIS techniques for adult spinal deformity.