Outcomes of Colorectal Surgery (CRS) at Department of Surgical Gastroenterology, Max Hospital (Saket): International quality at affordable Indian costs

Our team attended annual conference of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) held at Baltimore, USA April 2019. We presented 3 studies including one entitled ‘Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator^’.¹

In the following section we share some of the highlights of this study.

A recent study published in New England Journal of Medicine examined 30 -day readmission data of 479,471 patients from 3004 USA hospitals undergoing six major surgical procedures (colectomy and 5 other surgical procedures). The study concluded that following major surgical procedures, nearly one in seven patients are readmitted to the hospital within 30 days of discharge and readmission data is an indicator of quality of surgical care at any hospital.²

We therefore performed audit of colorectal surgery (CRS) outcomes at our department using American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) risk calculator - one of the most widely utilized and validated universal risk calculator for clinical audits.

The ACS NSQIP risk calculator was developed by utilizing data collected from 4.3 million operations performed across 780 hospitals participating in ACS NSQIP to predict outcomes for 1500 surgical procedures. The risk calculator estimates an individual’s risk of developing 18 different complications within 30 days after surgery.

The risk adjusted scoring systems such as ACS NSQIP risk calculator are important because in heterogeneous cohorts of surgery patients, crude postoperative morbidity and mortality as an outcome measure is misleading. Therefore, for meaningful conclusions from clinical audits and compare outcomes between different units or regions, risk adjusted patient outcomes are essential.

Our single centre observational study included 86 consecutive adult (≥ 18 years) patients who underwent elective or emergency, resective &/or reconstructive CRS from March 2013 to March 2018. Procedures such as appendicectomy, diverting colostomy, laparoscopic rectopexy were excluded from analysis. Data was accessed from institutional electronic health record system and pre-anaesthetic charts. ACS – NSQIP score for each patient was calculated. Actual outcomes were then compared with those predicted by risk calculators.

Of the 86 patients (60 Indians and 26 International) there were 56 males and 30 females with a mean age of 57 (range 18-93) years. Of these 59 (68.6%) underwent elective whereas 27(31.4%) had emergency CRS. We performed complete range of procedures for cancer as well as benign diseases. Sixty-two (72%) and 24 (38%) patients underwent open and minimally invasive procedures (laparoscopic -21 and robotic -3) respectively. The median length of stay was 08 (range 02-40) days. The mortality following elective and emergency operations was 1/59 (1.6%) and 8/27(29.6%) respectively. The readmission rate was 05 (5.8%)

Objective comparison between overall actual outcomes and those predicted by ACS – NSQIP risk calculator revealed no statistically significant difference in any of the parameters studied such as mortality, major complication, anastomotic leak, return to OT, surgical site infection length of stay, and readmission (Figure 1). 

Figure 1. Actual versus predicted outcomes by ACS-NSQIP risk calculator

Additionally there is significant cost advantage - all-inclusive costs of surgery (admission to discharge) were one fifth of the costs incurred for colectomy at comparable US NSQIP hospitals (Figure 2).

Figure 2. Comparison of costs for Colectomy at MSSH & US NSQIP hospitals

In conclusion at Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket outcomes of colorectal surgery are comparable to best of international centres - US NSQIP hospitals at affordable Indian costs.

References:

1. Vashistha N, Verma A and Singhal D. Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator. Surg Endosc. 2019;33:S241

2. Tsai TC, Joynt KE, Orav EJ et al. Variation in surgical readmission rates and quality of hospital care. N Engl J Med 2013;369:1134-42

      

      Authors:

Dr Nitin Vashistha MS, FIAGES, FACS
Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,

Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com

Tips & Tricks for Safe Anastomosis in Minimally Invasive Colorectal Surgery

Part B.   Intraoperative assessment of anastomotic integrity

This is second part in series of the blog 'Tips & tricks for safe anastomosis in minimally invasive colorectal surgery' (https://gicancerindia.blogspot.com/2019/07/tips-tricks-for-safe-anastomosis-in.html).

Anastomotic leak (AL) is the most feared complication of colorectal anastomosis (CRA) with a reported incidence of 8.1% after right hemicolectomy and 5.8% after high anterior resection and 10.8% after low anterior resection¹.

The attributes of 'Safe' intestinal anastomosis include tension free anastomosis between well vascularised bowel segments. In the era of open surgery, surgeons assessed the latter by a combination of observation (' healthy' color and pulastile bleeding at cut end of the bowel) and palpation (arterial pulsations in the mesocolon). In MIS, options available to the surgeons are more limited and viability of the colon following resection and subsequent anastomosis is determined largely by observing the color.

However the predictive accuracy of surgeons' clinical risk assessment for AL is reported to be low and is not influenced by training level (surgeon versus assistant surgeons)².

To make this assessment less observer dependent and to more objectively assess anastomotic integrity and tissue perfusion, several intraoperative tests have been introduced in clinical practice over last few years.

1.       Intraoperative air leak test (ALT): For left sided anastomosis, the test is simple and performed by insufflating the rectum with air while submerging the anastomosis³.

2.       Intraoperative flexible sigmoidoscopy for assessment of colorectal anastomosis (CRA): This is a safe and reliable method for direct assessment of anastomotic integrity as well as bleeding ⁴. More commonly performed in units where surgeons themselves are trained to perform colonoscopy.

3.       Intraoperative Indocyanine Green (ICG) fluorescence imaging: Intraoperative ICG imaging is a simple reproducible technique for real time assessment intestinal perfusion ¹. The data from non randomized studies on the subject suggests decreased anastomotic leak following ICGA^5,6. However results of a recent multicenter randomized controlled trial from Italy suggests that while ICGA can effectively assess vascularisation of the colic stump and anastomosis and led to further proximal resection in 11% of patients, there was no statistically significant reduction of anastomotic leak in the ICGA arm² . Further one multicenter phase II trial investigating the role of ICG imaging in elective CRS has reported that while the technique helped reduce AL rates in left sided resections  - particularly LAR, it did not add any value to outcomes following  ileocolic anastomoses ¹ .

Comments: We routinely do the intraoperative ALT for left sided anastomoses. For the right side, we perform extracorporeal anastomosis and have not introduced ICG fluorescence imaging. For elective CRS the overall AL in our unit is 5.08%

References:

1.       Ris E, Liot E, Buchs NC et al Multicenter phase II trial of near infrared imaging in elective colorectal surgery Br J Surg 2018;105:1359-1367

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.10844

2.       Karliczek A, Harlaar NJ, Zeebregts CG et al. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 2009;24(5):569-76

https://link.springer.com/article/10.1007%2Fs00384-009-0658-6

3.       Monson JR, Weiser MR, Buie WD et al. Practice parameters for the management of rectal cancer (Revised) Dis Colon Rectum. 2013;56(5):535-50.

https://journals.lww.com/dcrjournal/fulltext/2013/05000/Practice_Parameters_for_the_Management_of_Rectal.2.aspx

4.       Kamal T, Pai A, Velchuru VR et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis 2015;17(2):160-4

https://onlinelibrary.wiley.com/doi/abs/10.1111/codi.12809

5.       Shen R, Zhang Y, Wang T Indocyanine Green Fluorescence Angiography and the incidence of anastomotic leak after colorectal resection for colorectal cancer: A Meta Analysis. Dis Colon Rectum 2018;61(10):1228-1234

https://journals.lww.com/dcrjournal/fulltext/2018/10000/Indocyanine_Green_Fluorescence_Angiography_and_the.17.aspx

6.       Blanco-Colino R, Espin –Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta- analysis. Tech Coloproctol 2018;22(1):15-23

https://link.springer.com/article/10.1007%2Fs10151-017-1731-8

7.       Nardi De, Elmore U, Maggi G et al. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc 2019;doi:10.1007/s00464-019-06730-0

https://link.springer.com/article/10.1007%2Fs00464-019-06730-0

Authors:

Dr Nitin Vashistha MS, FIAGES, FACS
Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,

Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com