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Several large, randomized trials have shown that laparoscopic colon and rectal resections are safe, acceptable alternatives to open resections, with additional short-term benefits that include decreased pulmonary and gastrointestinal morbidity, improved pain control, fewer wound complications, and shorter hospital stays.1-4 Despite the accumulating evidence, more than 90% of all colorectal resections for cancer in the United States are still performed through a traditional open approach.5
In the most comprehensive review to date of the utilization patterns of minimally invasive surgery (MIS) in our country, Kemp and Finlayson5 reported that only 6.5% of all colorectal resections are performed by MIS. The proportion of MIS surgeries was only 4.3% for cancer and 8.2% for benign conditions. The utilization rate of MIS in patients with rectal cancer is even worse, with less than 2% of rectal resections performed laparoscopically. These same investigators found that patients treated laparoscopically tended to be younger (median age, 61 vs 66 yr; P <0.001) and tended to have fewer comorbid conditions (Charlson score of zero for 58.1% vs 37%; P <0.001), which runs contrary to logic: the patient group that could benefit the most from MIS (elderly and debilitated patients) was not the group receiving the procedure. Laparoscopic colon resections were more widely adopted in teaching than in nonteaching hospitals (5.1% vs 3.7%; P <0.001) and in urban than in rural hospitals (4.7% vs 2.2%; P <0.001).
The barriers to more widespread adoption of MIS for patients with colorectal cancer (CRC) are not yet fully understood, but they probably include lack of proper training, steep learning curves, and lack of a supportive environment in many hospitals. In order to circumvent these perceived obstacles, we created a minimally invasive CRC program at our institution with the intent of improving the quality of care by increasing the use of MIS in patients with CRC, while maintaining patient safety and oncologic standards.6 A programmatic approach to this problem, we thought, would enable us to rapidly increase the use of MIS and improve clinical outcomes.
The creation of our MIS program in 2008 involved several components, including
Since the inception of our MIS program, we have seen a dramatic increase in our use of MIS in patients with CRC. This increase has been associated with a significant decrease in our rates of conversion from laparoscopic operation to open surgery due to our inability to perform MIS safely or to intraoperative complications (Fig. 1).
In comparison with patients receiving open surgery, patients receiving laparoscopic resections benefited from much smaller incisions (Fig. 2), lower rates of wound complication, lower reoperative rates, and shorter hospital stays (Table I), without compromising oncologic safety (Table II).
In order to evaluate the impact of our MIS program on our hospital's financial bottom line, we compared the costs of laparoscopic surgery with those of open surgery in our CRC patients. In our experience, the use of MIS led to significant cost savings—both direct and indirect—of almost 50% ($17,047 vs $52,572 for open vs laparoscopic resections; P=0.01) in the surgical man-agement of CRC patients. These decreased treatment costs were largely the consequence of shorter lengths of stay and lower rates of wound complications in the patients who underwent laparoscopic resections. The advantages for hospitals include high surgical volumes (due to increased patient referrals into this type of program) and decreased hospitalization costs, higher revenues, and increased patient satisfaction.
Despite mounting evidence of substantial short-term advantages of MIS over open surgery, MIS remains grossly underused in patients with CRC. Our experience has shown that the development of a program to overcome the impediments to MIS enables a rapid increase in the use of MIS, with substantial benefits to both patients and hospitals.
The advantages for patients and hospitals are outlined above. The advantages for surgeons include higher operative volumes, excellent clinical outcomes, and, most importantly, the chance to do the right thing. Furthermore, the development of a MIS CRC program provides increased educational and research opportunities, enhancing the academic mission and paving the way for exciting new discoveries.
Address for reprints: Daniel Albo, MD, PhD, Division of Surgical Oncology, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden, Suite 1500, Houston, TX 77030
Presented at the Joint Session of the Denton A. Cooley Cardiovascular Surgical Society and the Michael E. DeBakey International Surgical Society; Austin, Texas, 10–13 June 2010