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

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.

Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open

“…This is in keeping with previously reported higher rates of APR in Sweden compared to the Netherlands. 31 Furthermore, re ective of the Swedish population, this study reports a relatively low median BMI when compared to many other western populations. This population based mirrors the real world and the distribution of disease stage, tumour height and the use of preoperative radiation and chemoradiation re ects this.…”

Association of Center-Level Operative Volume and Acute Outcomes following Robotic-Assisted Colectomy for Malignancy

“…The authors attributed this to the standardized training programs and higher per-surgeon volume in Sweden, which led to a shorter learning curve. 34 Appropriate patient selection during the early phases of the adoption of a robotic program has been proposed to lower MAE and cost. In an Austrian study evaluating the implementation of a robotic surgery program, MAE was particularly pronounced in complex cases during the early phases of enrollment.…”

“…38 For example, in the Netherlands, the number of hospitals performing robotic rectal cancer surgeries decreased between 2012 and 2018 despite an overall increase in the volume of overall surgical operations. 34 This was achieved by centralizing care at high-volume centers. However, such a national-level paradigm shift may not be feasible in the U.S., where healthcare delivery is still largely privatized and centralization may impair access to care.…”

Immunonutrition of perioperative therapy for colorectal cancer

“…With the advancement of instruments and the application of minimal invasive surgery, the outcomes have improved significantly in the modern era, leading to lower rates of surgical complications and better patient quality of life (less wound pain, shorter hospital stay, and earlier recovery of bowel function). [3] Malnutrition has been considered a risk factor for surgical complications among patients with major trauma, [4] breast cancer, [5] hepatocellular carcinoma, [6] and pancreatic cancer. [7] Malnutrition is less common in colorectal cancer patients than in gastric or periampullary cancer patients, [8] whereas overweight is more common, which may contribute to the occurrence of medical complications due to the associated cardiovascular dysfunction and poor physical reserve capacity.…”

“…With the advancement of instruments and the application of minimal invasive surgery, the outcomes have improved significantly in the modern era, leading to lower rates of surgical complications and better patient quality of life (less wound pain, shorter hospital stay, and earlier recovery of bowel function). [3]…”