P. J. Sweigert1, E. Eguia1, A. N. Kothari1, K. A. Ban1, M. H. Nelson1, M. S. Baker1, M. A. Singer1 1Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA
Introduction:
Prior studies have demonstrated that minimally invasive (MIS) approaches to colectomy are oncologically equivalent and associated with shorter lengths of stay, and reduced morbidity in comparison to open approaches to colectomy. There is also increasing evidence that prolonged operative time, especially that greater than 3 hours, is associated with increased rates of postoperative morbidity. Few studies examine the impact of operative time (OT) on the potential benefits afforded by MIS colectomy. We sought to determine if benefits associated with MIS colectomy are maintained in cases where OT is significantly prolonged.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) procedure targeted colectomy database was queried to identify adult patients who underwent elective left (LC) and right (RC) colectomy with anastomosis between 2011 and 2016. Emergent or converted cases, patients with preoperative infections, and observations with missing OT data were excluded. Forward stepwise multivariable logistic regression adjusting for demographic and clinical risk factors was used to compare outcomes for prolonged (4th quartile) MIS cases to average (2nd-3rd quartile) open cases with 30-day mortality or serious morbidity as the primary outcome of interest. Secondary 30-day outcomes included any morbidity, mortality, anastomotic leak, surgical site infection (SSI), and prolonged length of stay (LOS).
Results:
18,274 patients underwent RC and 54,550 LC during the study period. RC was most commonly performed for colon cancer (48.6%). Median OT for open RC was 132 min (IQR 92-189). That for MIS RC was 135 min (IQR 103-175), p=0.010. LC was also most commonly performed for colon cancer (44.9%). Median OT for open LC was 171 min (IQR 119-242). That for MIS LC was 173 min (IQR 129-231), p=0.001. No difference was seen in the adjusted primary outcome when prolonged MIS cases were compared to average open RC (OR 0.818, 95% CI: [0.660, 1.014]). Prolonged MIS cases did, however, show a significant benefit in comparison to average length open procedures for adjusted mortality or serious morbidity in LC (OR 0.824, 95% CI: [0.729-0.931]). Prolonged MIS approach was associated with significantly lower morbidity, SSI and LOS for both RC and LC relative to average open colectomy (Table 1).
Conclusion:
MIS approaches to colectomy are associated with improved rates of postoperative complications, serious morbidity and 30-day mortality relative to open approaches to colectomy. These benefits are maintained even with OT that extends beyond 3 hours. Surgeons performing elective MIS colectomy are justified in persisting with prolonged attempts at MIS colectomy.
