L. A. Sceats1, J. E. Tooley3, D. D. Bohl2, B. Read1, A. Trickey4, C. Kin1 1Stanford University,Surgery,Palo Alto, CA, USA 2Rush University Medical Center,Orthopedic Surgery,Chicago, IL, USA 3Stanford University,Internal Medicine,Palo Alto, CA, USA 4Stanford University,S-SPIRE Center,Stanford, CA, USA
Introduction:
Abdominoperineal resection (APR) is primarily used for low rectal cancers and is historically associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have increased in popularity. The differences in short-term complications between open and laparoscopic APR are poorly characterized. The purpose of this study was to determine the differences in frequency and timing of onset of postoperative complications between laparoscopic and open APR.
Methods:
A retrospective cohort study was completed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. All patients in the ACS-NSQIP database who underwent laparoscopic or open APR between 2011 and 2015 were identified by Current Procedure Terminology (CPT) codes. Selected patients’ demographic data and comorbidities were compared using Pearson’s χ2 tests. Utilization of the laparoscopic approach over time was evaluated with χ2 tests for trend. The 30-day occurrence rates of common postoperative complications were determined. Cox proportional hazard models were created to compare timing of complication onset between open and laparoscopic procedure groups while controlling for baseline demographics and comorbidities. Hazard ratios and hazard curves for postoperative day of onset were calculated for each complication. Differences in length of stay were analyzed using multivariate robust regression. Statistical analyses were conducted using Stata v14.2.
Results:
A total of 7681 patients undergoing laparoscopic or open APR were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). The percentage of APRs completed laparoscopically increased from 26% in 2011 to 40% in 2015 (p<0.001). Laparoscopic APR was associated with a lower total complication rate compared to open APR (36.0% vs. 50.1%, p<0.001). This was primarily driven by a decreased rate of transfusion (10.7% vs. 24.9%, p<0.001) and surgical site infection (15.5% vs. 21.2%, p<0.001). Laparoscopic APR was associated with a shorter length of stay (7.4 vs. 9.8 days, p<0.001) and decreased reoperation rate but similar rates of readmission and death. Laparoscopic patients were readmitted earlier, corresponding with earlier discharge date. Cardiopulmonary complications occurred earlier in the postoperative period while infectious complications occurred later. Wounds dehisced later (16.5 vs. 13.2 days, p=0.001) and strokes occurred later in laparoscopic surgical patients (12.2 vs. 8.8 days, p=0.027).
Conclusion:
Short-term complications following APR are common. Compared to open APR, laparoscopic APR is safe and has a shorter hospitalization, decreased rate of complications, and lower reoperation rate. Laparoscopic APR may be the preferable method for surgeons with the appropriate training and skill set.