National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes

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Abstract

Background

The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden.

Methods

Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes.

Results

A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018.

Conclusion

This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08974-1.

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Most cited references 45

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Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

Ahmedin Jemal, Lindsey A Torre, Rebecca Siegel … (2018)

This article provides a status report on the global burden of cancer worldwide using the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer, with a focus on geographic variability across 20 world regions. There will be an estimated 18.1 million new cancer cases (17.0 million excluding nonmelanoma skin cancer) and 9.6 million cancer deaths (9.5 million excluding nonmelanoma skin cancer) in 2018. In both sexes combined, lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer death (18.4% of the total cancer deaths), closely followed by female breast cancer (11.6%), prostate cancer (7.1%), and colorectal cancer (6.1%) for incidence and colorectal cancer (9.2%), stomach cancer (8.2%), and liver cancer (8.2%) for mortality. Lung cancer is the most frequent cancer and the leading cause of cancer death among males, followed by prostate and colorectal cancer (for incidence) and liver and stomach cancer (for mortality). Among females, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death, followed by colorectal and lung cancer (for incidence), and vice versa (for mortality); cervical cancer ranks fourth for both incidence and mortality. The most frequently diagnosed cancer and the leading cause of cancer death, however, substantially vary across countries and within each country depending on the degree of economic development and associated social and life style factors. It is noteworthy that high-quality cancer registry data, the basis for planning and implementing evidence-based cancer control programs, are not available in most low- and middle-income countries. The Global Initiative for Cancer Registry Development is an international partnership that supports better estimation, as well as the collection and use of local data, to prioritize and evaluate national cancer control efforts. CA: A Cancer Journal for Clinicians 2018;0:1-31. © 2018 American Cancer Society.

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Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial.

Pierre Guillou, Philip Quirke, Helen Thorpe … (2005)

Laparoscopic-assisted surgery for colorectal cancer has been widely adopted without data from large-scale randomised trials to support its use. We compared short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer to predict long-term outcomes. Between July, 1996, and July, 2002, we undertook a multicentre, randomised clinical trial in 794 patients with colorectal cancer from 27 UK centres. Patients were allocated to receive laparoscopic-assisted (n=526) or open surgery (n=268). Primary short-term endpoints were positivity rates of circumferential and longitudinal resection margins, proportion of Dukes' C2 tumours, and in-hospital mortality. Analysis was by intention to treat. This trial has been assigned the International Standard Randomised Controlled Trial Number ISRCTN74883561. Six patients (two [open], four [laparoscopic]) had no surgery, and 23 had missing surgical data (nine, 14). 253 and 484 patients actually received open and laparoscopic-assisted treatment, respectively. 143 (29%) patients underwent conversion from laparoscopic to open surgery. Proportion of Dukes' C2 tumours did not differ between treatments (18 [7%] patients, open vs 34 [6%], laparoscopic; difference -0.3%, 95% CI -3.9 to 3.4%, p=0.89), and neither did in-hospital mortality (13 [5%] vs 21 [4%]; -0.9%, -3.9 to 2.2%, p=0.57). Apart from patients undergoing laparoscopic anterior resection for rectal cancer, rates of positive resection margins were similar between treatment groups. Patients with converted treatment had raised complication rates. Laparoscopic-assisted surgery for cancer of the colon is as effective as open surgery in the short term and is likely to produce similar long-term outcomes. However, impaired short-term outcomes after laparoscopic-assisted anterior resection for cancer of the rectum do not yet justify its routine use.

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Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial.

Martijn van der Pas, Eva Haglind, Miguel Cuesta … (2013)

Laparoscopic surgery as an alternative to open surgery in patients with rectal cancer has not yet been shown to be oncologically safe. The aim in the COlorectal cancer Laparoscopic or Open Resection (COLOR II) trial was to compare laparoscopic and open surgery in patients with rectal cancer. A non-inferiority phase 3 trial was undertaken at 30 centres and hospitals in eight countries. Patients (aged ≥18 years) with rectal cancer within 15 cm from the anal verge without evidence of distant metastases were randomly assigned to either laparoscopic or open surgery in a 2:1 ratio, stratified by centre, location of tumour, and preoperative radiotherapy. The study was not masked. Secondary (short-term) outcomes-including operative findings, complications, mortality, and results at pathological examination-are reported here. Analysis was by modified intention to treat, excluding those patients with post-randomisation exclusion criteria and for whom data were not available. This study is registered with ClinicalTrials.gov, number NCT00297791. The study was undertaken between Jan 20, 2004, and May 4, 2010. 1103 patients were randomly assigned to the laparoscopic (n=739) and open surgery groups (n=364), and 1044 were eligible for analyses (699 and 345, respectively). Patients in the laparoscopic surgery group lost less blood than did those in the open surgery group (median 200 mL [IQR 100-400] vs 400 mL [200-700], p<0·0001); however, laparoscopic procedures took longer (240 min [184-300] vs 188 min [150-240]; p<0·0001). In the laparoscopic surgery group, bowel function returned sooner (2·0 days [1·0-3·0] vs 3·0 days [2·0-4·0]; p<0·0001) and hospital stay was shorter (8·0 days [6·0-13·0] vs 9·0 days [7·0-14·0]; p=0·036). Macroscopically, completeness of the resection was not different between groups (589 [88%] of 666 vs 303 [92%] of 331; p=0·250). Positive circumferential resection margin (<2 mm) was noted in 56 (10%) of 588 patients in the laparoscopic surgery group and 30 (10%) of 300 in the open surgery group (p=0·850). Median tumour distance to distal resection margin did not differ significantly between the groups (3·0 cm [IQR 2·0-4·8] vs 3·0 cm [1·8-5·0], respectively; p=0·676). In the laparoscopic and open surgery groups, morbidity (278 [40%] of 697 vs 128 [37%] of 345, respectively; p=0·424) and mortality (eight [1%] of 699 vs six [2%] of 345, respectively; p=0·409) within 28 days after surgery were similar. In selected patients with rectal cancer treated by skilled surgeons, laparoscopic surgery resulted in similar safety, resection margins, and completeness of resection to that of open surgery, and recovery was improved after laparoscopic surgery. Results for the primary endpoint-locoregional recurrence-are expected by the end of 2013. Ethicon Endo-Surgery Europe, Swedish Cancer Foundation, West Gothia Region, Sahlgrenska University Hospital. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

P. J. Tanis:

ORCID: http://orcid.org/0000-0002-3146-3310

p.j.tanis@amsterdamumc.nl

Journal

Journal ID (nlm-ta): Surg Endosc

Journal ID (iso-abbrev): Surg Endosc

Title: Surgical Endoscopy

Publisher: Springer US (New York )

ISSN (Print): 0930-2794

ISSN (Electronic): 1432-2218

Publication date (Electronic): 8 March 2022

Publication date PMC-release: 8 March 2022

Publication date (Print): 2022

Volume: 36

Issue: 8

Pages: 5986-6001

Affiliations

[1 ]GRID grid.10419.3d, ISNI 0000000089452978, Department of Surgery, , Leiden University Medical Centre, ; Albinusdreef 2, 2333 ZA Leiden, Netherlands

[2 ]GRID grid.511517.6, Dutch Institute for Clinical Auditing, ; Rijnsburgerweg 10, 2333 AA Leiden, Netherlands

[3 ]GRID grid.416648.9, ISNI 0000 0000 8986 2221, Department of Surgery, , Södersjukhuset, ; 118 83 Stockholm, Sweden

[4 ]Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76 Stockholm, Sweden

[5 ]Department of Surgery, Haagland Medisch Centrum, Lijnbaan 32, 2512 VA Den Haag, Netherlands

[6 ]GRID grid.509540.d, ISNI 0000 0004 6880 3010, Department of Surgery, , Amsterdam University Medical Centres, ; Meibergdreef 9, 1105 AZ Amsterdam, Netherlands

[7 ]GRID grid.24381.3c, ISNI 0000 0000 9241 5705, Department of Surgery, , Karolinska University Hospital, ; Anna Steckséns gata 53, 171 64 Solna, Sweden

[8 ]GRID grid.415868.6, ISNI 0000 0004 0624 5690, Department of Surgery, , Reinier de Graaf Groep, ; Reinier de Graafweg 5, 2625 AD Delft, Netherlands

[9 ]GRID grid.412367.5, ISNI 0000 0001 0123 6208, Department of Surgery, , Örebro University Hospital, ; von Rosens väg 1, 70185 Örebro, Sweden

[10 ]GRID grid.15895.30, ISNI 0000 0001 0738 8966, Department of Surgery, Faculty of Medicine and Health Sciences, , Örebro University, ; 70182 Örebro, Sweden

[11 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Surgery, Cancer Centre Amsterdam, , Amsterdam University Medical Centres, University of Amsterdam, ; De Boelelaan 1117, 1081 HV Amsterdam, Netherlands

Author information

P. J. Tanis http://orcid.org/0000-0002-3146-3310

Article

Publisher ID: 8974

DOI: 10.1007/s00464-021-08974-1

PMC ID: 9283170

PubMed ID: 35258664

SO-VID: f9b78362-d02f-4327-a544-36493bfb4358

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 3 July 2021

Date accepted : 31 December 2021

Funding

Funded by: serafimerlasarettet

Funded by: FundRef http://dx.doi.org/10.13039/501100009336, bengt ihres foundation;

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ScienceOpen disciplines: Surgery

Keywords: colorectal cancer,minimal invasive surgery,laparoscopy,robotic surgery,hospital volume,short-term outcomes

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ScienceOpen disciplines: Surgery

Keywords: colorectal cancer, minimal invasive surgery, laparoscopy, robotic surgery, hospital volume, short-term outcomes

National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes

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Karger: Oncology

Most cited references 45

Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial.

Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial.

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