- Email: [email protected]
Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database
j o u r n a l o f s u r g i c a l r e s e a r c h m a r c h 2 0 1 8 ( 2 2 3 ) 1 6 e2 1
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database Catherine H. Davis, MD, MPH,a,b Beverly A. Shirkey, PhD,c Linda W. Moore, MS, RDN,a Tanmay Gaglani, BS,d Xianglin L. Du, MB, MS, PhD,c H. Randolph Bailey, MD, FACS,a,d and Marianne V. Cusick, MD, MSPHa,d,* a
Department of Surgery, Houston Methodist Hospital, Houston, Texas Department of Epidemiology, The University of Texas School of Public Health, Houston, Texas c Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK d Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas b
article info
abstract
Article history:
Background: Laparoscopy, originally pioneered by gynecologists, was first adopted by gen-
Received 28 June 2017
eral surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical
Received in revised form
specialties and colorectal surgery for treatment of benign and malignant disease. Formal
24 August 2017
laparoscopic training became a required component of surgery residency programs as
Accepted 29 September 2017
validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some sur-
Available online xxx
geons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is
Keywords:
anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher
Colorectal surgery
risk or more acutely ill patients.
Laparoscopy
Methods: Using the American College of Surgeons (ACS) National Surgical Quality Improve-
Minimally invasive surgery
ment Program (NSQIP) database from 2005-2014, colorectal procedures were identified by
NSQIP
Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases. Results: During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.
* Corresponding author. The University of Texas Health Science Center at Houston, Houston Methodist Hospital, 6550 Fannin St. Suite 2307, Houston, TX 77030. Tel.: þ(713) 486 4613; fax: þ(713) 795 5737. E-mail address: [email protected] (M.V. Cusick). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2017.09.046
17
davis et al lap colorectal surgery trends
Conclusions: Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. ª 2017 Elsevier Inc. All rights reserved.
Introduction Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since that time, the technique has been widely adopted in the field of general and colorectal surgery.1,2 The first minimally invasive general surgery procedure, laparoscopic cholecystectomy, was introduced in 1989, and within 3 years, 81% of surgeons were performing cholecystectomy with laparoscopic technique.3 Proficiency was gained rapidly with experience: in an analysis of laparoscopic cholecystectomies performed in the 1990’s, operating room time decreased and patients with higher American Society of Anesthesiology (ASA) classifications were operated on as time and experience progressed with the procedure, but conversion rate, morbidity, and readmission remained the same.4 Although laparoscopic cholecystectomy has long been the gold-standard procedure for symptomatic cholelithiasis and chronic cholecystitis, a recent meta-analysis found that outcomes favored laparoscopy even in more acutely ill patients with acute cholecystitis.5 In the early history of laparoscopic general surgery, lack of formal training was a barrier to implementation of the new technique in surgical practice.6 To address this need, the Fundamentals of Laparoscopic Surgery (FLS) curriculum was introduced by the Society of American Gastrointestinal and Endoscopic Surgeons in 2007, and formal laparoscopic training became a required component of surgery residency programs 2 years later.7 FLS involves both a computerized didactic component and a simulation-based technical skills component and has been shown to improve surgeon performance in laparoscopy.8 Some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques despite integration of laparoscopic training into current surgical residency programs. A 2009 survey found that surgeons were more likely to perform laparoscopic colorectal surgery if they had been in practice less time, were male, had an academic hospital affiliation, or had minimally invasive surgical fellowship training.9 Two more recent surveys from 2015 on gynecologists and surgeons performing inguinal hernia repairs verified the positive link between younger surgeons and more specialized training with increased likelihood of use of laparoscopy.10,11 Barriers identified to the adoption of laparoscopy included lack of operating room time and formal training.9,10 In addition, nonadapters reported being more likely to perform laparoscopic surgery if a minimally invasive-trained surgeon mentor would visit their hospital for formal advanced laparoscopic training/proctoring.9,10 Given these challenges, although an overall increase in the use of laparoscopic techniques for colorectal surgery is anticipated over a
10-year period, it is unknown if an increase will be seen in higher risk or more acutely ill patients. This study aims to analyze trends in laparoscopic versus open surgery in colorectal surgery over a 10-year period. The American College of Surgeons (ACS) National Quality Improvement Program (NSQIP) database collects perioperative data from surgical patients in over 500 diverse participating institutions across the country and selected international locations. Given this diverse representation, 10 years of available data in the ACS-NSQIP database is uniquely suited for this trends-over-time analysis.
Methods Institutional Review Board was obtained for this retrospective cohort study, and reporting was followed according to STROBE guidelines.12 Using the ACS-NSQIP database from 2005 to 2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. A total of 46 unique CPTs were included: 31 open and 15 laparoscopic (Table 1). Procedures limited to small bowel, including appendectomies, were excluded; however, if they were performed in conjunction with colonic resection (i.e., ileocecectomy), they were included. Colorectal procedures with perineal or transsacral only approach were excluded. There were no exclusions based on International Classification of Diseases, Ninth Revision. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI) for each year. American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases. All statistical analyses were performed with Stata SE, version 14 (College Park, TX). BMI data were missing in 6073 cases (2.2% of cases), and ASA classification data were missing in 295 cases (0.1% of cases).
Table 1 e CPT codes included in analysis. Open surgery 44025, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44320, 44340, 45110, 45111, 45112, 45113, 45114, 45119, 45121, 45126, 45135, 45136, 45540, 45550, 46712
Laparoscopic surgery 44188, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 45395, 45397, 45400, 45402, 45499, 45540
18
j o u r n a l o f s u r g i c a l r e s e a r c h m a r c h 2 0 1 8 ( 2 2 3 ) 1 6 e2 1
Missing data were included as a separate category when examining percent of cases performed laparoscopically by descriptive categories. As robotic surgery is indicated with a modifier code and does not have its own set of CPT codes, the use of robotics is not captured in this data set.
Results A total of 277,376 colorectal cases were identified over the cumulative 10-year study period; of which, 114,359 (41.2%) were performed laparoscopically. 84.9% of procedures were coded as partial colectomy, 4.6% total colectomy, 6.7% proctectomy, 2.6% total proctocolectomy, and 1.2% other (Table 2). Over this time frame, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP (2005: 214 and 2014: 517). The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014 (Fig. 1). Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years, 44.2%), in overweight and obese patients (BMI: 25-29.9, 44.2%; BMI: 3034.9, 44.0%), and in lower ASA class patients (ASA 1, 55.3%, ASA 2, 51.3%). Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5, which is defined as a moribund person who is not expected to survive without the operation. From 2005-2014, the prevalence of laparoscopy increased from 23.3%-53.1%, 23.7%-51.7%, 22.1%-49.4%, and 20.5%-39.7% in groups aged 18-49, 50-64, 65-79, and 80þyears, respectively (Fig. 2). Within BMI groups, the use of laparoscopy increased from 15.9%-35.7%, 24.2%-49.2%, 25.4%-52.6%, 21.1%-53.0%, and 19.2%-47.5% in the underweight, normal weight, overweight, obese, and morbidly obese, respectively (Fig. 3). ASA class 1-4 patients all experienced large jumps in the use of laparoscopy as well, from 37.8%-62.2%, 27.7%-61.0%, 17.9%-45.5%, and 8.2%-21.2%, respectively, whereas ASA class 5 patients demonstrated no clear trend and had very low prevalence of laparoscopic surgery (0.7% over the cumulative time period) (Fig. 4). The percent of emergency cases receiving laparoscopic surgery also doubled during the 10-year period, from 5.5% in 2005 to 11.5% in 2014 (Fig. 5).
Fig. 1 e Overall prevalence of laparoscopic colorectal surgery by year.
surgical technique for colorectal surgery. A similar study was performed by Peterson et al. using the National Inpatient Sample (NIS) database between 1998-2009 with prevalence of laparoscopic colorectal procedures reported between 2003 (2%) and 2009 (29%).13 A total of 177,547 laparoscopic colorectal resections were identified. Although this study also reported an increase in the use of laparoscopy over time for specific procedures (right and left hemicolectomy, sigmoidectomy, and proctectomy), they did not assess the trends over time in the use of laparoscopy in any subpopulations. Furthermore, their analysis did not assess BMI or ASA classification of patients, which limits the ability to determine the health status of their cohort. In addition, they excluded emergent operations, presumably because during this time frame, very few emergency colorectal procedures were performed laparoscopically. Laparoscopy has been cautiously adopted in certain highrisk populations, including elderly and obese patients. As the elderly and obese are known to have more adverse perioperative outcomes, the use of laparoscopy in these patients
Discussion This study addresses a void in the current literature examining trends-over-time in the adoption of laparoscopic
Table 2 e Description of procedures included in analysis. Procedure type
Proportion of total cases analyzed (%)
Proportion performed laparoscopically (%)
Partial colectomy
84.9
43.2
Total colectomy
4.6
30.2
Proctectomy
6.7
21.4
Total proctocolectomy
2.6
29.5
Other
1.2
61.0
Fig. 2 e Prevalence of laparoscopic colorectal surgery by age group from 2005-2014.
davis et al lap colorectal surgery trends
Fig. 3 e Prevalence of laparoscopic colorectal surgery by BMI group from 2005-2014.
remains a controversial topic as more surgeons perform minimally invasive surgery and as our elderly and obese populations increase in size.14-20 Many studies suggest that while morbidity is higher in these populations compared to younger, healthier patients, laparoscopy is safe and often advantageous compared to open technique.14-20 However, these studies are often underpowered, and thus a formal conclusion is not possible.21 Further, more current studies are needed on representative populations, as much of the relevant literature is performed outside the United States or is becoming more outdated in the setting of increased experience and technical capability in the field of minimally invasive surgery. Other high-risk patients include those with higher ASA classification, or patients undergoing emergency surgery. The use of laparoscopic colectomy has been shown to have a benefit in both ASA class 3 and 4 patients over open resection.22 Although most emergency cases are still performed with open resection, laparoscopy has demonstrated superior outcomes in emergency colorectal surgery over open technique.23,24 Our results demonstrate a consistent increase in laparoscopic surgery not only in colorectal surgery overall but also in
Fig. 4 e Prevalence of laparoscopic colorectal surgery by ASA classification from 2005-2014.
19
Fig. 5 e Prevalence of emergency colorectal surgery performed laparoscopically from 2005-2014.
multiple subgroups. Laparoscopy increased in prevalence over the 10-year study period in all age groups (including those aged 65-79 and 80 years), all BMI groups (including the obese and morbidly obese), and most ASA classes. Interestingly, laparoscopy increased in all high-risk populations studied as well, including the elderly patients, obese and morbidly obese patients, in ASA classification 3 and 4 patients, and in emergency surgeries. These trends suggest not only that minimally invasive colorectal surgery appears to have become widely adopted but also that minimally invasive colorectal surgery is being increasingly performed on more complex or higher risk patients. Reasons for this observed increase in minimally invasive technique are likely multifold, including the implementation of FLS in general surgery residency programs, increased exposure to minimally invasive surgery during training, and reported improvement of perioperative outcomes in laparoscopic surgery.13,25 FLS was quickly adopted by surgeons in training and FLS certification became a requirement with the American Board of Surgery in 2009.8 Additionally, it has been shown that FLS training improves performance in real-world laparoscopy.26 Recent surgical trainees are exposed to more laparoscopy in the operating room in addition to simulation training. Review of the Accreditation Council for Graduate Medical Education (ACGME) case logs of general surgery residents demonstrated a consistent increase in the percent of minimally invasive surgery logged by residents, increasing from 8.9% to 21.8% of cases over a 20-year time period.27 In addition, multiple studies have demonstrated improved perioperative outcomes in laparoscopy over open surgery, which is another important factor contributing to increased adoption of minimally invasive technique.1,2,13 Despite a rapid increase in minimally invasive surgery, there is still a clinical role for open surgery, for example, in rectal cancer patients, given failure of laparoscopy to achieve noninferiority to open technique in recent large randomized controlled trials (ACOSOG Z6051, ALaCaRT).28,29 Thus, it is expected that laparoscopy will increase to a certain threshold,
20
j o u r n a l o f s u r g i c a l r e s e a r c h m a r c h 2 0 1 8 ( 2 2 3 ) 1 6 e2 1
where it will plateau. In addition, although minimally invasive surgery as a whole may rise, the increase in the use of robotic surgery may also affect the prevalence of laparoscopic surgery.1,25,30 As surgeons have become increasingly proficient in robotic technique, there has been an increase in roboticassisted resections of the lower bowel due to increased visibility and dexterity in the pelvis. Recently, there has been a push to use robotics in mesorectal excision as early studies showed that there is a decreased need for transition to open surgery when compared to laparoscopic excision.31 Furthermore, with increased experience, robotic-assisted lower anterior resections are being performed faster than those conducted laparoscopically with similar perioperative outcomes indicating some technical advantage.32 As the pervasiveness of robot-assisted surgery continues, certain procedures may preferentially be conducted robotically rather than laparoscopically.33 The present study is limited first by the inability to capture robotic cases, which are available in procedure-targeted files beginning in 2011 but not in the Participant Use Data Files, which date back to 2005. We do not have information on level of surgeon training or institution information, which likely varies widely between providers included. Finally, this is retrospective cohort data, and therefore, the baseline characteristics of the populations receiving laparoscopic versus open surgery are likely unequal, hence selection bias and unmeasured confounding might have affected the study findings.
Conclusions Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups (including the elderly), in all BMI classes (including the obese and morbidly obese), in most ASA classes (including ASA 3-4), and in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. This is a snapshot of the state of colorectal surgery as represented in the NSQIP database, which may be useful in planning future clinical trials examining the efficacy and survival outcomes of minimally invasive colorectal surgery.
Acknowledgment Authors’ contributions: C.H.D., B.A.S., L.W.M., X.L.D., H.R.B., and M.V.C. contributed for study design and concept. C.H.D., B.A.S., L.W.M., and M.V.C. participated in data collection and analysis. C.H.D., T.G., and M.V.C. drafted the manuscript. C.H.D., B.A.S., L.W.M., X.L.D., H.R.B., and M.V.C. carried out critical edits. The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
1. Tsui C, Klein R, Garabrant M. Minimally invasive surgery: national trends in adoption and future directions for hospital strategy. Surg Endosc. 2013;27:2253e2257. 2. Liska D, Lee SW, Nandakumar G. Laparoscopic surgery for benign and malignant colorectal diseases. Surg Laparosc Endosc Percutan Tech. 2012;22:165e174. 3. Escarce JJ, Bloom BS, Hillman AL, Shea JA, Schwartz JS. Diffusion of laparoscopic cholecystectomy among general surgeons in the United States. Med Care. 1995;33:256e271. 4. Wu JS, Dunnegan DL, Luttmann DR, Soper NJ. The evolution and maturation of laparoscopic cholecystectomy in an academic practice. J Am Coll Surg. 1998;186:554e560. discussion 60-61. 5. Coccolini F, Catena F, Pisano M, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015;18:196e204. 6. Torricelli FC, Barbosa JA, Marchini GS. Impact of laparoscopic surgery training laboratory on surgeon’s performance. World J Gastrointest Surg. 2016;8:735e743. 7. Peters JH, Fried GM, Swanstrom LL, et al. Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 2004;135:21e27. 8. Okrainec A, Soper NJ, Swanstrom LL, Fried GM. Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing. Surg Endosc. 2011;25:1192e1198. 9. Moloo H, Haggar F, Martel G, et al. The adoption of laparoscopic colorectal surgery: a national survey of general surgeons. Can J Surg. 2009;52:455e462. 10. Trevisonno M, Kaneva P, Watanabe Y, et al. A survey of general surgeons regarding laparoscopic inguinal hernia repair: practice patterns, barriers, and educational needs. Hernia. 2015;19:719e724. 11. Fuchs Weizman N, Maurer R, Einarsson JI, Vitonis AF, Cohen SL. Survey on barriers to adoption of laparoscopic surgery. J Surg Educ. 2015;72:985e994. 12. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344e349. 13. Peterson CY, Palazzi K, Parsons JK, Chang DC, Ramamoorthy SL. The prevalence of laparoscopy and patient safety outcomes: an analysis of colorectal resections. Surg Endosc. 2014;28:608e616. 14. Vallribera Valls F, Landi F, Espı´n Basany E, et al. Laparoscopyassisted versus open colectomy for treatment of colon cancer in the elderly: morbidity and mortality outcomes in 545 patients. Surg Endosc. 2014;28:3373e3378. 15. Xie M, Qin H, Luo Q, He X, Lan P, Lian L. Laparoscopic colorectal resection in Octogenarian patients: is it Safe? A systematic review and meta-analysis. Medicine (Baltimore). 2015;94:e1765. 16. Grailey K, Markar SR, Karthikesalingam A, Aboud R, Ziprin P, Faiz O. Laparoscopic versus open colorectal resection in the elderly population. Surg Endosc. 2013;27:19e30.
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17. Makino T, Shukla PJ, Rubino F, Milsom JW. The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg. 2012;255:228e236. 18. Xia X, Huang C, Jiang T, et al. Is laparoscopic colorectal cancer surgery associated with an increased risk in obese patients? A retrospective study from China. World J Surg Oncol. 2014;12:184. 19. Khoury W, Kiran RP, Jessie T, Geisler D, Remzi FH. Is the laparoscopic approach to colectomy safe for the morbidly obese? Surg Endosc. 2010;24:1336e1340. 20. Law WL, Chu KW, Tung PH. Laparoscopic colorectal resection: a safe option for elderly patients. J Am Coll Surg. 2002;195:768e773. 21. Schiphorst AH, Pronk A, Borel Rinkes IH, Hamaker ME. Representation of the elderly in trials of laparoscopic surgery for colorectal cancer. Colorectal Dis. 2014;16:976e983. 22. da Luz Moreira A, Kiran RP, Kirat HT, et al. Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs. Surg Endosc. 2010;24:1280e1286. 23. Mandrioli M, Inaba K, Piccinini A, et al. Advances in laparoscopy for acute care surgery and trauma. World J Gastroenterol. 2016;22:668e680. 24. Harji DP, Griffiths B, Burke D, Sagar PM. Systematic review of emergency laparoscopic colorectal resection. Br J Surg. 2014;101:e126ee133. 25. Li XX, Wang RJ. Core value of laparoscopic colorectal surgery. World J Gastrointest Endosc. 2015;7:1295e1299. 26. Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM. Fundamentals of laparoscopic surgery simulator
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training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg. 2010;199:115e120. Richards MK, McAteer JP, Drake FT, Goldin AB, Khandelwal S, Gow KW. A national review of the frequency of minimally invasive surgery among general surgery residents: assessment of ACGME case logs during 2 decades of general surgery resident training. JAMA Surg. 2015;150:169e172. Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopicassisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314: 1346e1355. Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314:1356e1363. Lendvay TS, Hannaford B, Satava RM. Future of robotic surgery. Cancer J. 2013;19:109e119. Pucci MJ, Beekley AC. Use of robotics in colon and rectal surgery. Clin Colon Rectal Surg. 2013;26:39e46. Melich G, Hong YK, Kim J, et al. Simultaneous development of laparoscopy and robotics provides acceptable perioperative outcomes and shows robotics to have a faster learning curve and to be overall faster in rectal cancer surgery: analysis of novice MIS surgeon learning curves. Surg Endosc. 2015;29:558e568. Iavazzo C, Gkegkes ID. Robotic assisted hysterectomy in obese patients: a systematic review. Arch Gynecol Obstet. 2016;293:1169e1183.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database Catherine H. Davis, MD, MPH,a,b Beverly A. Shirkey, PhD,c Linda W. Moore, MS, RDN,a Tanmay Gaglani, BS,d Xianglin L. Du, MB, MS, PhD,c H. Randolph Bailey, MD, FACS,a,d and Marianne V. Cusick, MD, MSPHa,d,* a
Department of Surgery, Houston Methodist Hospital, Houston, Texas Department of Epidemiology, The University of Texas School of Public Health, Houston, Texas c Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK d Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas b
article info
abstract
Article history:
Background: Laparoscopy, originally pioneered by gynecologists, was first adopted by gen-
Received 28 June 2017
eral surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical
Received in revised form
specialties and colorectal surgery for treatment of benign and malignant disease. Formal
24 August 2017
laparoscopic training became a required component of surgery residency programs as
Accepted 29 September 2017
validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some sur-
Available online xxx
geons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is
Keywords:
anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher
Colorectal surgery
risk or more acutely ill patients.
Laparoscopy
Methods: Using the American College of Surgeons (ACS) National Surgical Quality Improve-
Minimally invasive surgery
ment Program (NSQIP) database from 2005-2014, colorectal procedures were identified by
NSQIP
Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases. Results: During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.
* Corresponding author. The University of Texas Health Science Center at Houston, Houston Methodist Hospital, 6550 Fannin St. Suite 2307, Houston, TX 77030. Tel.: þ(713) 486 4613; fax: þ(713) 795 5737. E-mail address: [email protected] (M.V. Cusick). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2017.09.046
17
davis et al lap colorectal surgery trends
Conclusions: Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. ª 2017 Elsevier Inc. All rights reserved.
Introduction Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since that time, the technique has been widely adopted in the field of general and colorectal surgery.1,2 The first minimally invasive general surgery procedure, laparoscopic cholecystectomy, was introduced in 1989, and within 3 years, 81% of surgeons were performing cholecystectomy with laparoscopic technique.3 Proficiency was gained rapidly with experience: in an analysis of laparoscopic cholecystectomies performed in the 1990’s, operating room time decreased and patients with higher American Society of Anesthesiology (ASA) classifications were operated on as time and experience progressed with the procedure, but conversion rate, morbidity, and readmission remained the same.4 Although laparoscopic cholecystectomy has long been the gold-standard procedure for symptomatic cholelithiasis and chronic cholecystitis, a recent meta-analysis found that outcomes favored laparoscopy even in more acutely ill patients with acute cholecystitis.5 In the early history of laparoscopic general surgery, lack of formal training was a barrier to implementation of the new technique in surgical practice.6 To address this need, the Fundamentals of Laparoscopic Surgery (FLS) curriculum was introduced by the Society of American Gastrointestinal and Endoscopic Surgeons in 2007, and formal laparoscopic training became a required component of surgery residency programs 2 years later.7 FLS involves both a computerized didactic component and a simulation-based technical skills component and has been shown to improve surgeon performance in laparoscopy.8 Some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques despite integration of laparoscopic training into current surgical residency programs. A 2009 survey found that surgeons were more likely to perform laparoscopic colorectal surgery if they had been in practice less time, were male, had an academic hospital affiliation, or had minimally invasive surgical fellowship training.9 Two more recent surveys from 2015 on gynecologists and surgeons performing inguinal hernia repairs verified the positive link between younger surgeons and more specialized training with increased likelihood of use of laparoscopy.10,11 Barriers identified to the adoption of laparoscopy included lack of operating room time and formal training.9,10 In addition, nonadapters reported being more likely to perform laparoscopic surgery if a minimally invasive-trained surgeon mentor would visit their hospital for formal advanced laparoscopic training/proctoring.9,10 Given these challenges, although an overall increase in the use of laparoscopic techniques for colorectal surgery is anticipated over a
10-year period, it is unknown if an increase will be seen in higher risk or more acutely ill patients. This study aims to analyze trends in laparoscopic versus open surgery in colorectal surgery over a 10-year period. The American College of Surgeons (ACS) National Quality Improvement Program (NSQIP) database collects perioperative data from surgical patients in over 500 diverse participating institutions across the country and selected international locations. Given this diverse representation, 10 years of available data in the ACS-NSQIP database is uniquely suited for this trends-over-time analysis.
Methods Institutional Review Board was obtained for this retrospective cohort study, and reporting was followed according to STROBE guidelines.12 Using the ACS-NSQIP database from 2005 to 2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. A total of 46 unique CPTs were included: 31 open and 15 laparoscopic (Table 1). Procedures limited to small bowel, including appendectomies, were excluded; however, if they were performed in conjunction with colonic resection (i.e., ileocecectomy), they were included. Colorectal procedures with perineal or transsacral only approach were excluded. There were no exclusions based on International Classification of Diseases, Ninth Revision. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI) for each year. American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases. All statistical analyses were performed with Stata SE, version 14 (College Park, TX). BMI data were missing in 6073 cases (2.2% of cases), and ASA classification data were missing in 295 cases (0.1% of cases).
Table 1 e CPT codes included in analysis. Open surgery 44025, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 44320, 44340, 45110, 45111, 45112, 45113, 45114, 45119, 45121, 45126, 45135, 45136, 45540, 45550, 46712
Laparoscopic surgery 44188, 44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212, 44227, 45395, 45397, 45400, 45402, 45499, 45540
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Missing data were included as a separate category when examining percent of cases performed laparoscopically by descriptive categories. As robotic surgery is indicated with a modifier code and does not have its own set of CPT codes, the use of robotics is not captured in this data set.
Results A total of 277,376 colorectal cases were identified over the cumulative 10-year study period; of which, 114,359 (41.2%) were performed laparoscopically. 84.9% of procedures were coded as partial colectomy, 4.6% total colectomy, 6.7% proctectomy, 2.6% total proctocolectomy, and 1.2% other (Table 2). Over this time frame, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP (2005: 214 and 2014: 517). The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014 (Fig. 1). Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years, 44.2%), in overweight and obese patients (BMI: 25-29.9, 44.2%; BMI: 3034.9, 44.0%), and in lower ASA class patients (ASA 1, 55.3%, ASA 2, 51.3%). Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5, which is defined as a moribund person who is not expected to survive without the operation. From 2005-2014, the prevalence of laparoscopy increased from 23.3%-53.1%, 23.7%-51.7%, 22.1%-49.4%, and 20.5%-39.7% in groups aged 18-49, 50-64, 65-79, and 80þyears, respectively (Fig. 2). Within BMI groups, the use of laparoscopy increased from 15.9%-35.7%, 24.2%-49.2%, 25.4%-52.6%, 21.1%-53.0%, and 19.2%-47.5% in the underweight, normal weight, overweight, obese, and morbidly obese, respectively (Fig. 3). ASA class 1-4 patients all experienced large jumps in the use of laparoscopy as well, from 37.8%-62.2%, 27.7%-61.0%, 17.9%-45.5%, and 8.2%-21.2%, respectively, whereas ASA class 5 patients demonstrated no clear trend and had very low prevalence of laparoscopic surgery (0.7% over the cumulative time period) (Fig. 4). The percent of emergency cases receiving laparoscopic surgery also doubled during the 10-year period, from 5.5% in 2005 to 11.5% in 2014 (Fig. 5).
Fig. 1 e Overall prevalence of laparoscopic colorectal surgery by year.
surgical technique for colorectal surgery. A similar study was performed by Peterson et al. using the National Inpatient Sample (NIS) database between 1998-2009 with prevalence of laparoscopic colorectal procedures reported between 2003 (2%) and 2009 (29%).13 A total of 177,547 laparoscopic colorectal resections were identified. Although this study also reported an increase in the use of laparoscopy over time for specific procedures (right and left hemicolectomy, sigmoidectomy, and proctectomy), they did not assess the trends over time in the use of laparoscopy in any subpopulations. Furthermore, their analysis did not assess BMI or ASA classification of patients, which limits the ability to determine the health status of their cohort. In addition, they excluded emergent operations, presumably because during this time frame, very few emergency colorectal procedures were performed laparoscopically. Laparoscopy has been cautiously adopted in certain highrisk populations, including elderly and obese patients. As the elderly and obese are known to have more adverse perioperative outcomes, the use of laparoscopy in these patients
Discussion This study addresses a void in the current literature examining trends-over-time in the adoption of laparoscopic
Table 2 e Description of procedures included in analysis. Procedure type
Proportion of total cases analyzed (%)
Proportion performed laparoscopically (%)
Partial colectomy
84.9
43.2
Total colectomy
4.6
30.2
Proctectomy
6.7
21.4
Total proctocolectomy
2.6
29.5
Other
1.2
61.0
Fig. 2 e Prevalence of laparoscopic colorectal surgery by age group from 2005-2014.
davis et al lap colorectal surgery trends
Fig. 3 e Prevalence of laparoscopic colorectal surgery by BMI group from 2005-2014.
remains a controversial topic as more surgeons perform minimally invasive surgery and as our elderly and obese populations increase in size.14-20 Many studies suggest that while morbidity is higher in these populations compared to younger, healthier patients, laparoscopy is safe and often advantageous compared to open technique.14-20 However, these studies are often underpowered, and thus a formal conclusion is not possible.21 Further, more current studies are needed on representative populations, as much of the relevant literature is performed outside the United States or is becoming more outdated in the setting of increased experience and technical capability in the field of minimally invasive surgery. Other high-risk patients include those with higher ASA classification, or patients undergoing emergency surgery. The use of laparoscopic colectomy has been shown to have a benefit in both ASA class 3 and 4 patients over open resection.22 Although most emergency cases are still performed with open resection, laparoscopy has demonstrated superior outcomes in emergency colorectal surgery over open technique.23,24 Our results demonstrate a consistent increase in laparoscopic surgery not only in colorectal surgery overall but also in
Fig. 4 e Prevalence of laparoscopic colorectal surgery by ASA classification from 2005-2014.
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Fig. 5 e Prevalence of emergency colorectal surgery performed laparoscopically from 2005-2014.
multiple subgroups. Laparoscopy increased in prevalence over the 10-year study period in all age groups (including those aged 65-79 and 80 years), all BMI groups (including the obese and morbidly obese), and most ASA classes. Interestingly, laparoscopy increased in all high-risk populations studied as well, including the elderly patients, obese and morbidly obese patients, in ASA classification 3 and 4 patients, and in emergency surgeries. These trends suggest not only that minimally invasive colorectal surgery appears to have become widely adopted but also that minimally invasive colorectal surgery is being increasingly performed on more complex or higher risk patients. Reasons for this observed increase in minimally invasive technique are likely multifold, including the implementation of FLS in general surgery residency programs, increased exposure to minimally invasive surgery during training, and reported improvement of perioperative outcomes in laparoscopic surgery.13,25 FLS was quickly adopted by surgeons in training and FLS certification became a requirement with the American Board of Surgery in 2009.8 Additionally, it has been shown that FLS training improves performance in real-world laparoscopy.26 Recent surgical trainees are exposed to more laparoscopy in the operating room in addition to simulation training. Review of the Accreditation Council for Graduate Medical Education (ACGME) case logs of general surgery residents demonstrated a consistent increase in the percent of minimally invasive surgery logged by residents, increasing from 8.9% to 21.8% of cases over a 20-year time period.27 In addition, multiple studies have demonstrated improved perioperative outcomes in laparoscopy over open surgery, which is another important factor contributing to increased adoption of minimally invasive technique.1,2,13 Despite a rapid increase in minimally invasive surgery, there is still a clinical role for open surgery, for example, in rectal cancer patients, given failure of laparoscopy to achieve noninferiority to open technique in recent large randomized controlled trials (ACOSOG Z6051, ALaCaRT).28,29 Thus, it is expected that laparoscopy will increase to a certain threshold,
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where it will plateau. In addition, although minimally invasive surgery as a whole may rise, the increase in the use of robotic surgery may also affect the prevalence of laparoscopic surgery.1,25,30 As surgeons have become increasingly proficient in robotic technique, there has been an increase in roboticassisted resections of the lower bowel due to increased visibility and dexterity in the pelvis. Recently, there has been a push to use robotics in mesorectal excision as early studies showed that there is a decreased need for transition to open surgery when compared to laparoscopic excision.31 Furthermore, with increased experience, robotic-assisted lower anterior resections are being performed faster than those conducted laparoscopically with similar perioperative outcomes indicating some technical advantage.32 As the pervasiveness of robot-assisted surgery continues, certain procedures may preferentially be conducted robotically rather than laparoscopically.33 The present study is limited first by the inability to capture robotic cases, which are available in procedure-targeted files beginning in 2011 but not in the Participant Use Data Files, which date back to 2005. We do not have information on level of surgeon training or institution information, which likely varies widely between providers included. Finally, this is retrospective cohort data, and therefore, the baseline characteristics of the populations receiving laparoscopic versus open surgery are likely unequal, hence selection bias and unmeasured confounding might have affected the study findings.
Conclusions Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups (including the elderly), in all BMI classes (including the obese and morbidly obese), in most ASA classes (including ASA 3-4), and in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. This is a snapshot of the state of colorectal surgery as represented in the NSQIP database, which may be useful in planning future clinical trials examining the efficacy and survival outcomes of minimally invasive colorectal surgery.
Acknowledgment Authors’ contributions: C.H.D., B.A.S., L.W.M., X.L.D., H.R.B., and M.V.C. contributed for study design and concept. C.H.D., B.A.S., L.W.M., and M.V.C. participated in data collection and analysis. C.H.D., T.G., and M.V.C. drafted the manuscript. C.H.D., B.A.S., L.W.M., X.L.D., H.R.B., and M.V.C. carried out critical edits. The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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