Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 first St. Southwest, Rochester, MN, 55905, USA.
Surg Endosc. 2022 Jan;36(1):82-90. doi: 10.1007/s00464-020-08240-w. Epub 2021 Jan 6.
The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures.
All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30 kg/m). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort.
Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6 days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]).
This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.
本研究旨在确定机器人结肠切除术的全国应用趋势、随时间变化的转化率，以及转化对术后发病率的具体影响。与微创手术 (MIS) 相比，转为开放手术代表着微创手术的一个硬性终点，与 MIS 甚至传统开放手术相比，其结果更差。
研究纳入了美国外科医师学院质量改进计划 (ACS-NSQIP) 数据库中 2013 年至 2018 年期间接受腹腔镜或机器人择期结肠切除术的所有成年患者。分析了机器人使用率和转化率的全国趋势，总体上以及根据基础疾病（良性疾病、炎症性肠病 (IBD)、癌症）或肥胖症（体重指数 (BMI) ≥ 30 kg/m2）进行分析。通过多变量回归分析确定了手术转为开放的手术风险因素。进一步评估了总体和特定的术后 30 天并发症，并在转换患者和剩余队列之间进行了风险调整和比较。
在纳入的 66652 例手术中，有 5353 例（8.0%）转为开放手术。腹腔镜手术的转化率为 8.5%，机器人手术的转化率为 4.9%（p<0.0001）。总体而言，肥胖患者的转化率呈下降趋势，且在整个 6 年纳入期间均呈下降趋势。这一趋势与机器人平台利用率的增加相吻合。癌症、憩室炎和 IBD 的晚期疾病阶段以及手术时间延长等几个代表因素被确定为计划外转化的独立危险因素，而机器人方法是独立的保护因素（OR 0.44，p<0.0001）。计划外转化的患者更有可能出现术后并发症（OR 2.36；95%CI [2.21-2.51]）、住院时间≥6 天（OR 2.86；95%CI [2.67-3.05]）和 30 天死亡率（OR 2.28；95%CI [1.72-3.02]）。
本研究表明，6 年的纳入期间，总体上和肥胖患者中，转化率呈下降趋势，这与机器人平台利用率的增加相吻合。计划外转为开放手术与术后并发症风险增加相关。
