Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. PATIENTS AND METHODS: We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. RESULTS: Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CONCLUSIONS: CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.

Clinical factors associated with ultrashort length of stay in patients undergoing lower extremity bypass for peripheral arterial disease.

BACKGROUND: Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery pathways challenging. The aim of this study was to use a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease. METHODS: All patients undergoing LEB for peripheral artery disease in the National Surgical Quality Improvement Project database from 2011 to 2018 were included. Patients were divided into two groups based on the length of postoperative stay: ultrashort (≤2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS. RESULTS: Overall, 17,510 patients were identified who underwent LEB, of which 2678 patients (15.3%) had an ultrashort postoperative LOS (mean, 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean, 7.1 days). When compared with patients with standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%; P < .001), undergo elective surgery (86.1% vs 59.1%; P < .001), and be active smokers (52.1% vs 40.4%; P < .001). Patients with an ultrashort LOS were also more likely to have claudication as the indication for LEB (53.1% vs 22.5%; P < .001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%; P < .001), and have a prosthetic conduit (40.0% vs 29.9%; P < .001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%; P = .21); however, patients with an ultrashort LOS had a lower frequency of unplanned readmission (10.7% vs 18.8%; P < .001) and need for major reintervention (1.9% vs 5.6%; P < .001). On multivariable analysis, elective status (odds ratio , 2.66; 95% confidence interval [CI], 2.33-3.04), active smoking (OR, 1.18; 95% CI, 1.07-1.30), and lack of vein harvest (OR, 1.55; 95% CI, 1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR, 0.57; 95% CI, 0.51-0.63), tissue loss (OR, 0.30; 95% CI, 0.27-0.34), and totally dependent functional status (OR, 0.54; 95% CI, 0.35-0.84) were associated negatively with an ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR, 0.38; 95% CI, 0.19-0.75) and partially dependent (OR, 0.53; 95% CI, 0.32-0.88) functional status were persistently negatively associated with ultrashort LOS. CONCLUSIONS: Ultrashort LOS (≤2 days) after LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.

Mortality risk prediction for primary appendiceal cancer.

BACKGROUND: Accurately predicting survival in patients with cancer is crucial for both clinical decision-making and patient counseling. The primary aim of this study was to generate the first machine-learning algorithm to predict the risk of mortality following the diagnosis of an appendiceal neoplasm. METHODS: Patients with primary appendiceal cancer in the Surveillance, Epidemiology, and End Results database from 2000 to 2019 were included. Patient demographics, tumor characteristics, and survival data were extracted from the Surveillance, Epidemiology, and End Results database. Extreme gradient boost, random forest, neural network, and logistic regression machine learning models were employed to predict 1-, 5-, and 10-year mortality. After algorithm validation, the best-performance model was used to develop a patient-specific web-based risk prediction model. RESULTS: A total of 16,579 patients were included in the study, with 13,262 in the training group (80%) and 3,317 in the validation group (20%). Extreme gradient boost exhibited the highest prediction accuracy for 1-, 5-, and 10-year mortality, with the 10-year model exhibiting the maximum area under the curve (0.909 [±0.006]) after 10-fold cross-validation. Variables that significantly influenced the predictive ability of the model were disease grade, malignant carcinoid histology, incidence of positive regional lymph nodes, number of nodes harvested, and presence of distant disease. CONCLUSION: Here, we report the development and validation of a novel prognostic prediction model for patients with appendiceal neoplasms of numerous histologic subtypes that incorporate a vast array of patient, surgical, and pathologic variables. By using machine learning, we achieved an excellent predictive accuracy that was superior to that of previous nomograms.

National trends and outcomes of total proctocolectomy and completion proctectomy ileal pouch-anal anastomosis procedures for ulcerative colitis.

AIM: The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) or completion proctectomy with IPAA (CP-IPAA). METHODS: Adult UC patients who underwent TPC-IPAA or CP-IPAA were analysed retrospectively using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30-day overall and serious morbidity were identified using multivariable logistic regression. RESULTS: A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC-IPAA and 738 (43.5%) undergoing CP-IPAA. A greater proportion of TPC-IPAAs were performed each year (except in 2019) compared to CP-IPAAs over the study period (P trend <0.001). Unadjusted analysis showed comparable rates of overall (20.8% vs. 24.4%, P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC-IPAA and CP-IPAA patients. Robotic TPC-IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP-IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC-IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP-IPAA. CONCLUSIONS: Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP-IPAA or should delay surgery until they can be safely off those medications.

Intra- and Interpatient Drug Response Heterogeneity Exist in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Nongynecologic Cancers.

BACKGROUND: Select patients with peritoneal metastases are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We assayed for intra- and interpatient drug response heterogeneity through testing of patient-derived tumor organoids (PDTOs). METHODS: PDTOs were generated from CRS/HIPEC patients from December 2021 to September 2022 and subjected to an in vitro HIPEC drug screen. Drug response was assessed with a cell viability assay and cleaved caspase-3 staining. RESULTS: A total of 31 patients were consented for tissue collection. Viable tissue was harvested from 23, and PDTO generation was successful in 13 (56%). PDTOs were analyzed from six appendiceal, three colorectal, two small bowel, one gastric, and one adrenal tumor. Drug screen results were generated in as few as 7 days (62%), with an average time of 12 days. Most patients received mitomycin-C (MMC) intraoperatively (n = 9); however, in only three cases was this agent considered the optimal choice in vitro. Three sets of PDTOs were resistant (defined as > 50% PDTO viability) to all agents tested and two were pan-sensitive (defined as 3 or more agents with < 50% PDTO viability). In three patients, organoids were generated from multiple metastatic sites and intrapatient drug response heterogeneity was observed. CONCLUSIONS: Both intra- and interpatient drug response heterogeneity exist in patients undergoing CRS/HIPEC for nongynecologic abdominal cancers. Caution must be used when interpreting patient response to chemotherapeutic agents based on a single site of testing in those with metastatic disease.

Short-Stay Left Colectomy for Colon Cancer: Is It Safe?

BACKGROUND: Advances in surgical practices have decreased hospital length of stay (LOS) after surgery. This study aimed to determine the safety of short-stay (≤24-hour) left colectomy for colon cancer patients in the US. STUDY DESIGN: Adult colon cancer patients who underwent elective left colectomies were identified using the American College of Surgeons NSQIP database (2012 to 2021). Patients were categorized into 4 LOS groups: LOS 1 day or less (≤24-hour short stay), 2 to 4, 5 to 6, and 7 or more. Primary outcomes were 30-day postoperative overall and serious morbidity. Secondary outcomes were 30-day mortality and readmission. Multivariable logistic regression was performed to explore the association between LOS and overall and serious morbidity. RESULTS: A total of 15,745 patients who underwent left colectomies for colon cancer were identified with 294 (1.87%) patients undergoing short stay. Short-stay patients were generally younger and healthier with lower 30-day overall morbidity rates (LOS ≤1 day: 3.74%, 2 to 4: 7.38%, 5 to 6: 16.12%, and ≥7: 37.64%, p < 0.001). Compared with patients with LOS 2 to 4 days, no differences in mortality and readmission rates were observed. On adjusted analysis, there was no statistical difference in the odds of overall (LOS 2 to 4 days: odds ratio 1.90, 95% CI 1.01 to 3.60, p = 0.049) and serious morbidity (LOS 2 to 4 days: odds ratio 0.86, 95% CI 1.42 to 1.76, p = 0.672) between the short-stay and LOS 2 to 4 days groups. CONCLUSIONS: Although currently performed at low rates in the US, short-stay left colectomy is safe for a select group of patients. Attention to patient selection, refinement of clinical pathways, and close follow-up may enable short-stay colectomies to become a more feasible reality.

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC).

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC. PATIENTS AND METHODS: We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity. RESULTS: Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile. CONCLUSIONS: An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

Prevalence and outcomes of select rare vascular conditions in females: A descriptive review.

Rare vascular conditions frequently pose a diagnostic and therapeutic dilemma for health care providers. Several of these conditions have distinct relevance to females populations but, due to their infrequency, there has been little reported on the outcomes of rare vascular conditions specifically in females populations. We performed a literature review of a selection of three rare vascular conditions known to either disproportionately affect females (median arcuate ligament syndrome and fibromuscular dysplasia) or have unique manifestations in females populations (vascular Ehlers-Danlos syndrome). We performed a descriptive review of the literature focused on these three vascular conditions and identified aspects of the current available research describing sex-based differences in prevalence, any pathophysiology explaining the observed sex-based differences, and the contribution of sex to outcomes for each disease process. In addition, considerations for pregnant females with respect to each rare vascular disease process are discussed.

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis.

BACKGROUND: The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. METHODS: Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. RESULTS: A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. CONCLUSION: Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Feasibility of robotic multivisceral resections in colorectal cancer patients: a NSQIP-based study.

Multivisceral robotic surgery may be an alternative to sequential procedures in select patients with colorectal cancer who are diagnosed with synchronous lesions or in those who require additional procedures at the time of resection. The aim of this study was to assess utilization of the robot for multivisceral resections and compare the surgical outcomes of this approach to laparoscopic resections. Adult colorectal surgery patients who underwent a colectomy or proctectomy and a concurrent abdominal surgery procedure in the American College of Surgeons NSQIP database (2016-2021) were included. The primary outcomes were 30-day postoperative overall and serious morbidity. Factors associated with morbidity were assessed using a multivariable logistic regression. Of the 3875 patients who underwent simultaneous multivisceral resections, 397 (10.3%) underwent a robotic approach and 962 (24.8%) a laparoscopic approach. Gynecological procedures (38%) comprised the largest proportion of concurrent procedures followed by hepatic resections (18%). On unadjusted analysis, rates of overall morbidity (25.4% vs. 30.0%) and serious morbidity (12.1% vs 12.0%) did not differ between the robotic and laparoscopic approach groups, respectively. The rate of conversion to open was lower for the robotic compared to laparoscopic approach (9.3% vs. 28.8%, p < 0.001), and length of stay was shorter (4 vs. 5, p < 0.001). On adjusted analysis, there was no significant difference in overall (OR 0.87, 95% CI 0.65-1.16, p = 0.34) or serious morbidity (OR 1.12, 95% CI 0.75-1.65, p = 0.59) between the two approaches even after concurrent procedure risk stratification. Robotic multivisceral resections can be performed with acceptable overall and serious morbidity in select patients with colorectal cancer. Rates of conversion and length of stay may be decreased with a robotic approach, and future research is needed to determine the optimal operative approach in this patient population.

Neighborhood-Level Socioeconomic Disadvantage Predicts Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignancy.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) improves survival in select patients with peritoneal metastases (PM), but the impact of social determinants of health on CRS/HIPEC outcomes remains unclear. PATIENTS AND METHODS: A retrospective review was conducted of a multi-institutional database of patients with PM who underwent CRS/HIPEC in the USA between 2000 and 2017. The area deprivation index (ADI) was linked to the patient's residential address. Patients were categorized as living in low (1-49) or high (50-100) ADI residences, with increasing scores indicating higher socioeconomic disadvantage. The primary outcome was overall survival (OS). Secondary outcomes included perioperative complications, hospital/intensive care unit (ICU) length of stay (LOS), and disease-free survival (DFS). RESULTS: Among 1675 patients 1061 (63.3%) resided in low ADI areas and 614 (36.7%) high ADI areas. Appendiceal tumors (n = 1102, 65.8%) and colon cancer (n = 322, 19.2%) were the most common histologies. On multivariate analysis, high ADI was not associated with increased perioperative complications, hospital/ICU LOS, or DFS. High ADI was associated with worse OS (median not reached versus 49 months; 5 year OS 61.0% versus 28.2%, P < 0.0001). On multivariate Cox-regression analysis, high ADI (HR, 2.26; 95% CI 1.13-4.50; P < 0.001), cancer recurrence (HR, 2.26; 95% CI 1.61-3.20; P < 0.0001), increases in peritoneal carcinomatosis index (HR, 1.03; 95% CI 1.01-1.05; P < 0.001), and incomplete cytoreduction (HR, 4.48; 95% CI 3.01-6.53; P < 0.0001) were associated with worse OS. CONCLUSIONS: Even after controlling for cancer-specific variables, adverse outcomes persisted in association with neighborhood-level socioeconomic disadvantage. The individual and structural-level factors leading to these cancer disparities warrant further investigation to improve outcomes for all patients with peritoneal malignancies.

National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease.

BACKGROUND: Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD. METHODS: Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed. RESULTS: The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results. CONCLUSION: The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Impact of preoperative chemotherapy on perioperative morbidity in combined resection of colon cancer and liver metastases.

BACKGROUND: Preoperative chemotherapy, or neoadjuvant therapy (NAC) can be used to improve resectability but can also have hepatotoxic effects on the future liver remnant. The purpose of this study was to investigate the impact of NAC on 30-day morbidity among patients undergoing a resection of primary colon cancer and synchronous liver metastases (sLM). METHODS: This was a retrospective study using the National Surgical Quality Improvement Program database (2012-2020). The association between NAC and 30-day overall morbidity, the primary outcome, was assessed. Subgroup analyses for low and high-risk procedures were performed. RESULTS: Among 968 patients who underwent the combined resection, 571 (58.99%) received NAC. There was a lower rate of 30-day overall morbidity among patients who received NAC (34.50% vs. 41.56%, p = 0.026) and no difference in rates of postoperative liver failure, bile leak, need for invasive intervention for hepatic procedure, and anastomotic leak. On adjusted analyses, patients who received NAC had decreased odds of overall morbidity (OR 0.73, 95% CI 0.55-0.97, p = 0.031) compared to patients who did not receive NAC. On subgroup analyses, patients who received NAC prior to a low risk combined resection had lower rates of overall morbidity on both adjusted and unadjusted analyses. Among those undergoing high-risk combined resections, there was no difference in overall morbidity. DISCUSSION AND CONCLUSION: Patients who are deemed to be candidates for preoperative chemotherapy can proceed with planned neoadjuvant chemotherapy prior to combined resection of primary colon cancer and sLM as preoperative neoadjuvant chemotherapy does not appear to be associated with increased postoperative morbidity.

Procedure-specific risks of robotic simultaneous resection of colorectal cancer and synchronous liver metastases.

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Although prior studies have reported that a simultaneous approach to resections in these patients can lead to increased rates of complications, emerging literature shows that minimally invasive surgical (MIS) approaches can mitigate this additional morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,721 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016 to 2021. Of these patients, 345 (20%) underwent resections by an MIS approach, defined as either laparoscopic (n = 266, 78%) or robotic (n = 79, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had open surgeries. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post-operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open (8% vs. 22%, p = 0.004) and median LOS (5 vs. 6 days, p = 0.022) was significantly lower for robotic compared to laparoscopic group. This study, which is the largest national cohort of simultaneous CRC and CRLM resections, supports the safety and potential benefits of a robotic approach in these patients.

Simultaneous resection of colorectal cancer and synchronous colorectal liver metastases: A risk stratified analysis of the NSQIP database.

BACKGROUND AND OBJECTIVES: Over 25% of patients diagnosed with colorectal cancer (CRC) will develop colorectal liver metastases (CRLM). Controversy exists over the surgical management of these patients. This study aims to investigate the safety of a simultaneous surgical approach by stratifying patients based on procedure risk and operative approach. METHODS: Using ACS-NSQIP (2016-2020), patients with CRC who underwent isolated colorectal, isolated hepatic, or simultaneous resections were identified. Colorectal and hepatic procedures were stratified by morbidity risk (high vs. low) and operative approach (open vs. minimally invasive). Thirty-day overall morbidity was compared between risk matched isolated and simultaneous resection groups. RESULTS: A total of 65 417 patients were identified, with 1550 (2.4%) undergoing simultaneous resections. A total of 1207 (77.9%) underwent a low-risk colorectal and low-risk liver resection. On multivariate analysis, there was no significant difference in overall morbidity between patients who had a simultaneous open high-risk colorectal/low-risk hepatic procedure compared to patients who had an isolated open high-risk colorectal procedure (odds ratio: 1.19; 95% confidence interval: 0.94-1.50; p = 0.148). All other combinations of simultaneous procedures had statistically significant higher rates of morbidity than the isolated group. CONCLUSIONS: Simultaneous resection of colorectal and synchronous CRLM is associated with an increased risk of morbidity in most circumstances in a risk stratified analysis, although rates of readmission and reoperation were not increased. Minimally invasive surgical approaches may significantly mitigate this morbidity.