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. 2022 Aug;36(8):5986-6001.
doi: 10.1007/s00464-021-08974-1. Epub 2022 Mar 8.

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

A K Warps  1   2 , D Saraste  3   4 , M Westerterp  5 , R Detering  6 , A Sjövall  4   7 , A Martling  4   7 , J W T Dekker  8 , R A E M Tollenaar  1   2 , P Matthiessen  9   10 , P J Tanis  11 ; Dutch ColoRectal Audit and Swedish Colorectal Cancer Registry
Affiliations

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

A K Warps et al. Surg Endosc. 2022 Aug.

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.

Keywords: Colorectal cancer; Hospital volume; Laparoscopy; Minimal invasive surgery; Robotic surgery; Short-term outcomes.

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Conflict of interest statement

Anne-Loes K. Warps, Marinke Westerterp, Robin Detering, Annika Sjövall, Anna Martling, Jan Willem T. Dekker, Rob A.E.M. Tollenaar, Peter Matthiessen, and Pieter J. Tanis have no conflicts of interests and financial ties to disclose. Deborah Saraste has no conflicts of interests to disclose, but received funding from the foundation Serafimerlasarettet and the Bengt Ihre Foundation.

Figures

Fig. 1
Fig. 1
A Time trend (2012–2018) of elective open vs. minimally invasive surgery for colon cancer in the Netherlands and Sweden. B Time trend (2012–2018) of elective open vs. minimally invasive surgery for rectal cancer in the Netherlands and Sweden
Fig. 2
Fig. 2
A Number of hospitals performing elective minimal invasive surgery in Sweden and the Netherlands, categorized in four hospital volume groups, during 2012–2018. B Number of hospitals performing elective minimal invasive surgery in Sweden and the Netherlands, categorized in hospital volume groups, during 2012–2018
Fig. 3
Fig. 3
A Time trend (2014–2018) laparoscopic vs. robotic surgery for colon cancer in the Netherlands and Sweden. B Time trend (2014–2018) laparoscopic vs. robotic surgery for rectal cancer in the Netherlands and Sweden. C Time trend (2012–2018) converted laparoscopic vs. robotic surgery for colon and rectal cancer in the Netherlands and Sweden
Fig. 4
Fig. 4
A Short term outcome after elective minimal invasive surgery for colon cancer in the Netherlands (2012–2013) (n = 6255) and Sweden (2017–2018) (n = 2503). B Short term outcome after elective minimal invasive surgery for rectal cancer in the Netherlands (2012–2013) (n = 2996) and Sweden (2017–2018) (n = 1348)
Fig. 5
Fig. 5
A Forest plots of incomplete resection margin after MIS for cT-3 colon cancer. B Forest plot of overall complications after MIS for cT-3 colon cancer. C Forest plot of reoperations after MIS for cT-3 colon cancer. D Forest plot of readmission after MIS for cT-3 colon cancer. AOR Adjusted Odds Ratio. Error bars present the 95% CI. The reference category and exact AOR with 95% CI can be found in Supplementary Table S1
Fig. 6
Fig. 6
A Forest plots of incomplete resection margin after MIS for cT-3 rectal cancer. B Forest plot of overall complications after MIS for cT-3 rectal cancer. C Forest plot of reoperations after MIS for cT-3 rectal cancer. D Forest plot of readmission after MIS for cT-3 rectal cancer. AOR Adjuster Odds Ratio. Error bars present the 95% CI. The reference category and exact AOR with 95% CI can be found in Supplementary Table S2
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