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Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study.

Kethman WC, Harris AHS, Morris AM, Shelton A, Kirilcuk N, Kin C. Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study. Diseases of The Colon and Rectum. 2020 Jan 1; 63(1):46-52.

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Abstract:

BACKGROUND: Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes. OBJECTIVE: The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection. DESIGN: This is a multicenter, quasiexperimental cohort study using propensity score weighting. SETTINGS: Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS: Adult patients who underwent rectal cancer resection in 2016 were included. MAIN OUTCOME MEASURES: The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated. RESULTS: Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002). LIMITATIONS: This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings. CONCLUSIONS: Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70. RESULTADOS ONCOLÓGICOS Y PERIOPERATORIOS DE LOS ABORDAJES LAPAROSCÓPICOS, ABIERTOS Y ROBÓTICOS PARA LA RESECCIÓN DEL CÁNCER RECTAL: UN ESTUDIO DE COHORTE MULTICÉNTRICO Y PONDERADO DEL PUNTAJE DE PROPENSIÓN: Se ha demostrado que los enfoques mínimamente invasivos reducen las complicaciones del sitio quirúrgico sin comprometer los resultados oncológicos.El objetivo principal de este estudio es evaluar las tasas de resección oncológica exitosa y los resultados postoperatorios entre los abordajes laparoscópico, abierto y robótico para la resección del cáncer rectal.Este es un estudio de cohorte cuasi-experimental multicéntrico que utiliza la ponderación de puntaje de propensión.Las intervenciones se realizaron en hospitales que participan en el Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Se incluyeron pacientes adultos que se sometieron a resección de cáncer rectal en 2016.El resultado primario fue una variable compuesta que indicaba una resección oncológica exitosa, definida como márgenes negativos distales y radiales con al menos 12 ganglios linfáticos evaluados.Entre 1,028 resecciones de cáncer rectal, 206 (20%) fueron abordadas por vía laparoscópica, 192 (18.7%) robóticamente y 630 (61.3%) abiertas. Después de ponderar el puntaje de propensión, no hubo diferencias sociodemográficas o clínicas preoperatorias significativas entre las subcohortes. En comparación con el abordaje laparoscópico, los abordajes abiertos y robóticos se asociaron con una menor probabilidad de resección oncológica exitosa (ORadj = 0.64; IC 95%, 0.43-0.94 y ORadj = 0.60; IC 95%, 0.37-0.97), y el abordaje abierto se asoció con una mayor probabilidad de complicaciones del sitio quirúrgico (ORadj = 2.53; IC 95%, 1.61-3.959). En comparación con el abordaje laparoscópico, el abordaje abierto se asoció con una estadía más prolongada (6.8 frente a 8.6 días, p = 0.002).Este fue un estudio de cohorte observacional que utilizó un conjunto de datos clínicos preexistentes. A pesar de la metodología de puntuación de propensión ajustada, la confusión no medida puede contribuir a nuestros hallazgos.Las resecciones que se abordaron por vía laparoscópica tuvieron más probabilidades de lograr el éxito oncológico. Los enfoques mínimamente invasivos no alargaron los tiempos quirúrgicos y proporcionaron beneficios de la reducción de las complicaciones del sitio quirúrgico y la disminución de la duración de la estadía postoperatoria. Se necesitan más estudios para aclarar los resultados clínicos y los factores que influyen en la elección del enfoque. Vea video resumen en http://links.lww.com/DCR/B70.





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