- Email: [email protected]
1031 The Learning Curve of Laparoscopic Rectal Resection for Cancer: A Single-Center Experience
at our medical center. 1,638 (5.2%) were captured by the sampling method of NSQIP, including 32 pancreatic resections. Our institutional pancreatic database captured 75 patients having pancreatic resection during the same time period and included NSQIP occurrence categories and pancreatic fistula (PF) rates (ISGPF grade A,B, C). NSQIP nurses were instructed in ISGPF definitions and asked to retrospectively categorize patients with PF. Postoperative occurrences were compared. Results: NSQIP captured equivalent outcomes to the pancreatic surgery database including rates of pancreatic fistula (table 1). However, grading of pancreatic fistula by NSQIP increased the ISGPF grade in 3 cases. Two cases were upgraded from A to B, due to the discovery of a drain in-situ in the outpatient setting. NSQIP discovered readmission of one patient, upgrading this patient from grade A to B. All three upgrades were not detected by the pancreatic registry, which only focused on inhospital morbidities. Conclusions: The data collected within the NSQIP at our institution compares favorably to a procedure specific clinical database. The sampling methodology inherent to NSQIP did not compromise the validity of outcome observations. The quality of data collection by NSQIP nurse reviewers may lead to more accurate appraisal and interpretation of outcomes due to lack of self reporting bias. The collected PF data were sufficient to allow accurate grading according the ISGPF system. These findings suggest that NSQIP may be further improved by consensus development of procedure specific outcome variables. NSQIP Pancreatic Surgery Outcomes
Patients were excluded if they underwent emergent procedures, were ASA class 5, or had metastatic disease. RESULTS: Of the 3,059 patients who underwent colectomy for cancer, 837 (27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no significant differences in age, comorbidities, ASA class, or BMI between patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likelihood of developing any adverse event (includes wound, cardiac, pulmonary, renal, neurologic, or hematologic complications) compared to OC (14.6% vs. 21.7%; OR 0.64, 95% CI 0.51-0.81, P<0.0001) (Table). Mean length of stay was significantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P<0.0001). There was no difference between LAC and OC in the rate of returns to the operating room (5.5% vs. 5.8%, P=0.79) or 30-day mortality (1.4% vs. 1.8%, P=0.53). CONCLUSIONS: LAC was utilized in one-quarter of patients with colon cancer. LAC was associated with lower morbidity and length of stay in select patients. 1033 Patient Demographics and Surgeon Volume in Pancreatic Resection Mortality Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level. METHODS: Using the Nationwide Inpatient Sample (NIS), discharge records for all nontrauma PR (n=3,705) were examined from 1998-2005. Surgeons were divided into two groups: high volume (HV; >=5 operations / year) or low volume (LV; < 5 /year). The Elixhauser index adjusted for patient comorbidity. We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient/hospital factors. To eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores. RESULTS: 128 HV and 1,329 LV surgeons performed 3,705 PR in 449 hospitals across 11 states that report surgeon identifier information over the 8year period. Patients who underwent PR by HV surgeons were more likely to be male, white race, and a resident of a high-income zip code (p < 0.05). HV surgeons had a lower unadjusted mortality compared to LV surgeons (2.5% vs. 6.8% p<0.0001). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance and surgery by HV surgeon (Table). Propensity scoring was used to create matched HV and LV groups; when HV surgeons performed PR an in-hospital mortality benefit was found across all groups. CONCLUSIONS: PR by a HV surgeon in this cohort was independently associated with a 60% reduction in in-hospital mortality. Removal of potential selection bias still resulted in improved outcomes after PR by HV surgeons. To our knowledge, this is the first population-based case-controlled evidence that demonstrates improved in-hospital mortality after PR is directly related to surgeon volume. Logistic Regression of Operative Mortality
SSI - surgical site infection. 1031 The Learning Curve of Laparoscopic Rectal Resection for Cancer: A SingleCenter Experience Marco Montorsi, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi, Riccardo Rosati
SSAT Abstracts
Laparoscopic rectal resection (LRR) has been shown to be feasible but challenging. The role of the learning curve in this surgery is not fully elucidated. To evaluate its impact, we prospectively collected, in two consecutive periods, operative and outcome data of pts submitted to LRR for cancer at a single institute performed by four surgeons equally experienced in laparoscopic surgery. Methods: From November 1999 to May 2007, 141 patients with rectal cancer were treated by laparoscopy. Learning curve was evaluated in two consecutive periods, 1999 to 2003 (first period) and 2004 to 2007 (second period). The evaluated variables were: operative data (operative time, conversion rate, intraoperative complications), short-term outcomes (postoperative complications, mortality, lenght of hospital stay, readmission rate), and oncological outcomes (site of the tumor, number of lymphnodes, resection margins, port recurrence) Results: Number of patients (71 and 70), demographic data and oncological stage were similar in the two periods. No differences were found in operative time (274 and 294 minutes, p 0.12), intraoperative (7% and 12.9%, p 0.25) and postoperative complications rate (19.7% vs 17.1%, p 0.69). Anastomotic leakages occured in 8 patients, equally in the first (11.3%) and in the second period (11.4%, p 0.97). Lenght of hospital stay decreased in the second period (9 vs 8 days, p 0.18). There were no readmission in hospital after discharge in both groups. No differences were observed among the four surgeons in operative data and outcomes. The number of resected lymphnodes per patient (18) was the same in the two periods. There were statistically significant differences in the distribution of tumor site (percentage of the tumors located in the mid and lower rectum was 45.1% in the first period and 72.9% in the second period, p 0.01) and in conversion rate (23.9% vs 11.4%, p 0.05). There were 2 microscopical infiltrations of the distal margin (2.8%) and 1 port site metastasis (1.4%), all in the second period. Five yrs overall and disease free survival rates were 82.1% and 75.6%. Disease free survival rate was significantly lower when conversion to open surgery was required (78.7% vs 61.8%, p 0.04). Conclusions: When performed by experienced surgeons, LRR for cancer is feasible, safe and oncologically effective since the beginning of the experience. The parameters which significantly changed during the learning curve were conversion rate and the anatomic site of the rectal tumors. Operative time and morbidity did not show an improvement, probably due to a different case-mix in the second period (more distal tumours).
1034 Are Seasoned Surgeons Still Safe in a Laparoscopic Surgical Crisis? Kinga A. Powers, Scott Rehrig, Noel Irias, Mark P. Callery, Steven D. Schwaitzberg, Daniel B. Jones Seasoned surgeons are confronted with emerging technologies which were not part of their formal residency training. Our aim was to compare technical and team performances of surgeons of different ages and expertise. We hypothesize that seasoned surgeons are less prepared to deal with a laparoscopic surgical crisis than younger, expert laparoscopic surgeons. Methods: Six seasoned surgeons (age 55-83) were compared to six control, expert laparoscopic surgeons (age 34-53). In a simulation mock operating room, surgeons established pneumoperitoneum, trocar access, and managed an intraabdominal hemorrhage in a previously described and validated model of an abdomen. Blood loss and time to control hemorrhage were measured. Videos were evaluated as part of an approved IRB. Surgeons' performance in the simulated operating endosuite was assessed using described and validated technical and team performance scales. Statistics were by SAS/STAT software with p <0.05 significance. Results: All seasoned surgeons when confronted with the use of unfamiliar technologies (Veress needle and optical trocar) used junior assistants appropriately. All control surgeons achieved intraabdominal pneumoperitoneum and trocar entry themselves. Mean blood loss for seasoned surgeons and control surgeons was 2.7 versus 2.8 liters, respectively (p=NS). Bleeding was successfully managed laparoscopically by two senior teams and one control team. On hemorrhage recognition, senior surgeons converted after 2:40 min vs. 3:30 min for the control surgeons (p=NS). Overall technical and team abilities of both groups were comparable. On debriefing, 85% of all surgeons recommended simulation for recertification. Conclusions: Seasoned surgeons use their assistant surgeons well and are safe even when confronted with emerging technologies. Conversion to laparotomy addresses
1032 Short-Term Outcomes After Laparoscopic-Assisted Compared to Open Colectomy for Cancer Karl Y. Bilimoria, David J. Bentrem, Heidi Nelson, Steven J. Stryker, Clifford Y. Ko, Nathaniel J. Soper BACKGROUND: Randomized clinical trials have demonstrated that laparoscopic-assisted colectomy (LAC) outcomes are comparable to open colectomy (OC) when performed by experts; however, LAC has not been examined in a multi-institutional setting outside of trials. The objectives of this study were to assess differences in perioperative outcomes for LAC compared to OC. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project's (NSQIP) participant-use dataset, patients were identified who underwent colectomy for cancer at 120 participating hospitals in 2005-2006. Multiple logistic regression was used to assess the risk-adjusted association between surgical approach (LAC vs. OC) and 30-day outcomes. Propensity scores were used to adjust for group differences.
A-859
SSAT Abstracts
Patients were excluded if they underwent emergent procedures, were ASA class 5, or had metastatic disease. RESULTS: Of the 3,059 patients who underwent colectomy for cancer, 837 (27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no significant differences in age, comorbidities, ASA class, or BMI between patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likelihood of developing any adverse event (includes wound, cardiac, pulmonary, renal, neurologic, or hematologic complications) compared to OC (14.6% vs. 21.7%; OR 0.64, 95% CI 0.51-0.81, P<0.0001) (Table). Mean length of stay was significantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P<0.0001). There was no difference between LAC and OC in the rate of returns to the operating room (5.5% vs. 5.8%, P=0.79) or 30-day mortality (1.4% vs. 1.8%, P=0.53). CONCLUSIONS: LAC was utilized in one-quarter of patients with colon cancer. LAC was associated with lower morbidity and length of stay in select patients. 1033 Patient Demographics and Surgeon Volume in Pancreatic Resection Mortality Robert W. Eppsteiner, Nicholas Csikesz, Jennifer F. Tseng, Shimul A. Shah Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level. METHODS: Using the Nationwide Inpatient Sample (NIS), discharge records for all nontrauma PR (n=3,705) were examined from 1998-2005. Surgeons were divided into two groups: high volume (HV; >=5 operations / year) or low volume (LV; < 5 /year). The Elixhauser index adjusted for patient comorbidity. We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient/hospital factors. To eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores. RESULTS: 128 HV and 1,329 LV surgeons performed 3,705 PR in 449 hospitals across 11 states that report surgeon identifier information over the 8year period. Patients who underwent PR by HV surgeons were more likely to be male, white race, and a resident of a high-income zip code (p < 0.05). HV surgeons had a lower unadjusted mortality compared to LV surgeons (2.5% vs. 6.8% p<0.0001). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance and surgery by HV surgeon (Table). Propensity scoring was used to create matched HV and LV groups; when HV surgeons performed PR an in-hospital mortality benefit was found across all groups. CONCLUSIONS: PR by a HV surgeon in this cohort was independently associated with a 60% reduction in in-hospital mortality. Removal of potential selection bias still resulted in improved outcomes after PR by HV surgeons. To our knowledge, this is the first population-based case-controlled evidence that demonstrates improved in-hospital mortality after PR is directly related to surgeon volume. Logistic Regression of Operative Mortality
SSI - surgical site infection. 1031 The Learning Curve of Laparoscopic Rectal Resection for Cancer: A SingleCenter Experience Marco Montorsi, Matteo Rottoli, Stefano Bona, Paolo P. Bianchi, Riccardo Rosati
SSAT Abstracts
Laparoscopic rectal resection (LRR) has been shown to be feasible but challenging. The role of the learning curve in this surgery is not fully elucidated. To evaluate its impact, we prospectively collected, in two consecutive periods, operative and outcome data of pts submitted to LRR for cancer at a single institute performed by four surgeons equally experienced in laparoscopic surgery. Methods: From November 1999 to May 2007, 141 patients with rectal cancer were treated by laparoscopy. Learning curve was evaluated in two consecutive periods, 1999 to 2003 (first period) and 2004 to 2007 (second period). The evaluated variables were: operative data (operative time, conversion rate, intraoperative complications), short-term outcomes (postoperative complications, mortality, lenght of hospital stay, readmission rate), and oncological outcomes (site of the tumor, number of lymphnodes, resection margins, port recurrence) Results: Number of patients (71 and 70), demographic data and oncological stage were similar in the two periods. No differences were found in operative time (274 and 294 minutes, p 0.12), intraoperative (7% and 12.9%, p 0.25) and postoperative complications rate (19.7% vs 17.1%, p 0.69). Anastomotic leakages occured in 8 patients, equally in the first (11.3%) and in the second period (11.4%, p 0.97). Lenght of hospital stay decreased in the second period (9 vs 8 days, p 0.18). There were no readmission in hospital after discharge in both groups. No differences were observed among the four surgeons in operative data and outcomes. The number of resected lymphnodes per patient (18) was the same in the two periods. There were statistically significant differences in the distribution of tumor site (percentage of the tumors located in the mid and lower rectum was 45.1% in the first period and 72.9% in the second period, p 0.01) and in conversion rate (23.9% vs 11.4%, p 0.05). There were 2 microscopical infiltrations of the distal margin (2.8%) and 1 port site metastasis (1.4%), all in the second period. Five yrs overall and disease free survival rates were 82.1% and 75.6%. Disease free survival rate was significantly lower when conversion to open surgery was required (78.7% vs 61.8%, p 0.04). Conclusions: When performed by experienced surgeons, LRR for cancer is feasible, safe and oncologically effective since the beginning of the experience. The parameters which significantly changed during the learning curve were conversion rate and the anatomic site of the rectal tumors. Operative time and morbidity did not show an improvement, probably due to a different case-mix in the second period (more distal tumours).
1034 Are Seasoned Surgeons Still Safe in a Laparoscopic Surgical Crisis? Kinga A. Powers, Scott Rehrig, Noel Irias, Mark P. Callery, Steven D. Schwaitzberg, Daniel B. Jones Seasoned surgeons are confronted with emerging technologies which were not part of their formal residency training. Our aim was to compare technical and team performances of surgeons of different ages and expertise. We hypothesize that seasoned surgeons are less prepared to deal with a laparoscopic surgical crisis than younger, expert laparoscopic surgeons. Methods: Six seasoned surgeons (age 55-83) were compared to six control, expert laparoscopic surgeons (age 34-53). In a simulation mock operating room, surgeons established pneumoperitoneum, trocar access, and managed an intraabdominal hemorrhage in a previously described and validated model of an abdomen. Blood loss and time to control hemorrhage were measured. Videos were evaluated as part of an approved IRB. Surgeons' performance in the simulated operating endosuite was assessed using described and validated technical and team performance scales. Statistics were by SAS/STAT software with p <0.05 significance. Results: All seasoned surgeons when confronted with the use of unfamiliar technologies (Veress needle and optical trocar) used junior assistants appropriately. All control surgeons achieved intraabdominal pneumoperitoneum and trocar entry themselves. Mean blood loss for seasoned surgeons and control surgeons was 2.7 versus 2.8 liters, respectively (p=NS). Bleeding was successfully managed laparoscopically by two senior teams and one control team. On hemorrhage recognition, senior surgeons converted after 2:40 min vs. 3:30 min for the control surgeons (p=NS). Overall technical and team abilities of both groups were comparable. On debriefing, 85% of all surgeons recommended simulation for recertification. Conclusions: Seasoned surgeons use their assistant surgeons well and are safe even when confronted with emerging technologies. Conversion to laparotomy addresses
1032 Short-Term Outcomes After Laparoscopic-Assisted Compared to Open Colectomy for Cancer Karl Y. Bilimoria, David J. Bentrem, Heidi Nelson, Steven J. Stryker, Clifford Y. Ko, Nathaniel J. Soper BACKGROUND: Randomized clinical trials have demonstrated that laparoscopic-assisted colectomy (LAC) outcomes are comparable to open colectomy (OC) when performed by experts; however, LAC has not been examined in a multi-institutional setting outside of trials. The objectives of this study were to assess differences in perioperative outcomes for LAC compared to OC. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project's (NSQIP) participant-use dataset, patients were identified who underwent colectomy for cancer at 120 participating hospitals in 2005-2006. Multiple logistic regression was used to assess the risk-adjusted association between surgical approach (LAC vs. OC) and 30-day outcomes. Propensity scores were used to adjust for group differences.
A-859
SSAT Abstracts