Keller Deborah S, Flores-Gonzalez Juan R, Ibarra Sergio, Madhoun Nisreen, Tahilramani Reena, Mahmood Ali, Haas Eric M
Colorectal Surgical Associates, Houston, TX, USA.
Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX, USA.
Surg Endosc. 2016 Jun;30(6):2207-16. doi: 10.1007/s00464-015-4479-0. Epub 2015 Sep 28.
There is an increasing emphasis on optimizing and measuring surgical quality. The safety and efficacy of minimally invasive techniques have been proven; however, direct comparison of outcomes across platforms has not been performed. Our goal was to compare operative times and quality across three minimally invasive platforms in colorectal surgery.
A prospective database was reviewed for elective minimally invasive surgery (MIS) cases from 2008 to 2014. Patients were stratified into multiport laparoscopic, single-incision laparoscopic (SILS) or robotic-assisted laparoscopic approaches (RALS). Demographics, perioperative, and postoperative outcomes were analyzed. Multivariate regression analysis was used to predict the demographic and procedural factors and outcomes associated with each platform. The main outcome measures were operative time and surgical quality by approach.
A total of 1055 cases were evaluated-28.4 % LAP, 18.5 % RALS, and 53.1 % SILS. RALS had the most complex patients, pathology, and procedures. The main diagnosis for RALS was rectal cancer (49.5 %), patients predominantly underwent pelvic surgery (72.8 %), had higher rates of neoadjuvant chemoradiation (p < 0.001) and stoma creation (p < 0.001). RALS had the longest operative time and highest complication and readmissions rates (all p < 0.001). Multiport patients were older than SILS and RALS (p = 0.021), had the most intraoperative complications (p < 0.001), conversions (p < 0.001), and had the longest length of stay (p = 0.001). SILS had the shortest operative times (p < 0.001), length of stay (p = 0.001), and lowest rates of complications (p < 0.001), readmissions (p < 0.001), and unplanned reoperation (p = 0.014). All platforms offered high quality (HARM score 0) from overall short LOS, low readmission, and mortality rates.
Multiport, RALS, and SILS each serve a distinct demographic and disease profile and have predictable outcomes. All have risks and benefits, but offer overall high-quality care with a composite of LOS, readmission, and mortality rates. Operative times were directly associated with readmission rates. As all three platforms offer good quality, the choice of which MIS approach to use should be guided by demographics and disease process.
目前越来越强调优化和衡量手术质量。微创技术的安全性和有效性已得到证实；然而，尚未对不同平台的手术结果进行直接比较。我们的目标是比较结直肠手术中三种微创平台的手术时间和质量。
回顾了一个前瞻性数据库中2008年至2014年的择期微创手术（MIS）病例。患者被分为多端口腹腔镜手术、单切口腹腔镜手术（SILS）或机器人辅助腹腔镜手术（RALS）。分析了人口统计学、围手术期和术后结果。采用多变量回归分析来预测与每个平台相关的人口统计学、手术因素和结果。主要结局指标是各手术方式的手术时间和手术质量。
共评估了1055例病例——28.4%为腹腔镜手术，18.5%为机器人辅助腹腔镜手术，53.1%为单切口腹腔镜手术。机器人辅助腹腔镜手术的患者、病理和手术最为复杂。机器人辅助腹腔镜手术的主要诊断为直肠癌（49.5%），患者主要接受盆腔手术（72.8%），新辅助放化疗（p<0.001）和造口术（p<0.001）的发生率较高。机器人辅助腹腔镜手术的手术时间最长，并发症和再入院率最高（均p<0.001）。多端口腹腔镜手术患者比单切口腹腔镜手术和机器人辅助腹腔镜手术患者年龄更大（p=0.021），术中并发症（p<0.001）、中转手术（p<0.001）最多，住院时间最长（p=0.001）。单切口腹腔镜手术的手术时间最短（p<0.001）、住院时间最短（p=0.001），并发症（p<0.001）、再入院（p<0.001）和非计划再次手术（p=0.014）发生率最低。所有平台的总体住院时间短、再入院率低和死亡率低，手术质量高（HARM评分0）。
多端口腹腔镜手术、机器人辅助腹腔镜手术和单切口腹腔镜手术各自针对不同的人群和疾病特征，且具有可预测的结果。所有手术方式都有风险和益处，但总体上提供高质量的医疗服务，综合考虑住院时间、再入院率和死亡率。手术时间与再入院率直接相关。由于这三种平台都能提供良好的手术质量，选择哪种微创手术方式应根据患者的人口统计学特征和疾病进程来决定。
