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International Journal of Colorectal Disease

, Volume 33, Issue 6, pp 663–681 | Cite as

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

  • Gabriela Batista Rodríguez
  • Andrea Balla
  • Santiago Corradetti
  • Carmen Martinez
  • Pilar Hernández
  • Jesús Bollo
  • Eduard M. Targarona
Review

Abstract

Background

“Big data” refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

Methods

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

Results

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

Conclusions

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Keywords

NSQIP NIS Big data Laparoscopic colorectal surgery Systematic literature review 

Introduction

Electronic revolution has provided access to a wide variety of information; therefore, the amount of data available is growing daily, which has created the need to develop big databases in order to process and analyze the information [1]. In general, the term “big data” refers to large datasets with quantities on the order of magnitude of a terabyte (1012 gigabytes), and special techniques must be used to evaluate this information data in a scientifically meaningful way [1, 2].

The usefulness of these big databases is applied in many areas, one of which is healthcare, where those large clinical databases can contribute to improve patient care through: identification of risk factors and developing prediction models, observational studies comparing interventions, exploration of variation between healthcare providers, and as a supplementary source of data for another study [3].

Some of the most recognized databases in healthcare are the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and the National (Nationwide) Inpatient Sample (NIS) [4, 5]. Both big databases mentioned before have enabled the information for medical investigation related to surgical procedures [4, 5]. The applicability of information obtained from both sources in the laparoscopic colorectal surgery has awaked a special interest for this review.

The hypothesis is that big databases in healthcare can provide valuable and quality in information the area of laparoscopic colorectal surgery in order to improve patient’s care. The aim of the present systematic review is to evaluate the type and topic as well as the clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

Materials and methods

The present study is a systematic literature review performed according to Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines [6] in which, only papers about laparoscopic colorectal surgery data based on ACS-NSQIP and NIS databases are included.

Data sources

The ACS-NSQIP database was the first nationally validated, risk-adjusted, outcome-based program developed by the Veterans Health Administration with the aim to measure and improve the quality of surgical care in the USA [4, 7]. Therefore, since 1990s, the application of ACS-NSQIP program has extended and nowadays, it has spread to 455 hospitals [8].

The NIS is a publicly available all-payer inpatient healthcare database that contains data of around 20% of all inpatient admissions in the USA; information such as national trends in healthcare utilization, access, cost, quality, and perioperative outcomes is collected [5, 9]. Records around 5 to 8 million hospitalizations from about 1000 hospital are included [10].

All data from these registries can be risk adjusted, and this makes it possible to standardize surgical procedures and patients’ characteristics and to perform comparisons among hospitals [11, 12].

Search strategy

The research was carried out on PubMed database using the keywords: “laparoscopic surgery” AND “NSQIP,” “laparoscopic surgery” AND “NIS,” “laparoscopic colorectal surgery” AND “NSQIP,” “laparoscopic colorectal surgery” AND “NIS”. The search revealed 350 published papers, the first one on 2007 up to February 2017.

The studies were included in the review according to the following criteria: (1) English language, (2) studies including only adults, (3) papers with a main objective directly related to laparoscopic colorectal surgery, and (4) no restriction about number of patients for each study was applied.

Studies were excluded if: (1) results regarding laparoscopic colorectal surgery were secondary outcomes and (2) systematic review, meta-analysis, comment paper, correspondence, and letter to authors or editors. Data were extracted by three surgeon reviewers (G.B.R., A.B., and S.C.).

Main outcomes directly related to laparoscopic colorectal surgery were extracted and analyzed.

Results

Fifty-two articles were excluded for overlap between searches. Following the inclusion and exclusion criteria, 243 studies were excluded based on title and abstract. The remaining 55 studies were fully analyzed and of these, three studies were also excluded because laparoscopic (LAP) colorectal surgery was not primary outcome. Four more articles were later included, because they were considered of interest and met the inclusion criteria. They were not found through the keyword searches but during the search for articles while writing the discussion (Fig. 1). Finally, 56 studies, published between 2007 and February 2017, were included in the present review, as shown in the literature search diagram (Fig. 1). All articles included were retrospective studies.
Fig. 1

Literature search diagram

The included articles were categorized in groups according to the main topic: 27 articles contained outcomes related to surgical techniques comparisons, 12 articles showed morbidity and perioperatory results, nine papers analyzed specific disease related outcomes, and eight articles exposed sociodemographic, economic, and academic training impact results (Table 1).
Table 1

Articles from big databases (ACS-NSQIP and NIS) according to main topic

Main topic

Number of articles

Surgical technique-related outcomes

27

Perioperative and morbidity related outcomes

12

Specific disease-related outcomes

9

Sociodemographic, economic, and academic outcomes

8

Surgical technique-related outcomes

For the 20 papers comparing surgical techniques, diverse outcomes of elective or emergent, total, or partial colorectal resections were reported, according to the different approaches: LAP, hand-assisted laparoscopic surgery (HALS), single-incision laparoscopic surgery (SILS), robotic, or open (Tables 2 and 3).
Table 2

Comparison of surgical techniques: laparoscopic vs open colectomies

Author, year

Aim

Number of patients

Type of surgery

Outcomes

McCloskey, 2007 [13]

Comparison of techniques for high risk patient

Tot: 45 LAP:23

O: 22

Elective partial and total colectomy in high risk patients

LAP is safe in patients with high risk for operative. Similar morbidity and mortality.

Ballian, 2012 [14]

Comparison of outcomes between LAP and O colectomy

T: 3552

LAP: 341 O: 3211

Emergent partial and total colectomy with anastomosis

LAP emergent colon resection with improved postoperative outcomes in a small number of patients, with favorable co-morbidity. LAP emergent colon resection with primary anastomosis compared to open, has similar morbidity and mortality rates LAP with shorter LOS

Cone, 2012 [15]

Evaluation the impact of LAP approach on mortality and morbidity for elective colectomy

T: 24730

LAP:10409

O: 14321

Elective partial colectomy

LAP approach has a lower rate of morbidity but this technique does not independently influence mortality

Wilson, 2014 [16]

Comparison incidence of complications between LAP and open colectomy

T:37249 LAP:15643 O: 21606

Elective and emergency partial colectomy (excludes rectum)

LAP shorter LOS, lower morbidity. Similar mortality. Exclusion of rectal surgery

Bilimoria, 2008 [17]

Determination whether certain complications occurred more frequently after LAP vs O colectomy for colon cancer

T: 3059

LAP: 837

O: 2222

Elective partial colectomy

LAP colectomy was associated with lower morbidity compared to open, in select patients, specifically for infectious complications

Ozhathil, 2011 [18]

Comparison of outcomes between the LAP and open approaches for colectomies and its trends through the years

T: 48247 LAP: 15634

O: 32781

Elective and emergent total and partial colectomy

The number of LAP colectomies has increased while open colectomies have correspondingly decreased.

The morbidity is lower for LAP and it has improved through the years

Webb, 2012 [19]

Comparison of efficacy of the LAP vs open approach from the perspective of the ICU level complications

T: 45645 LAP: 12455

O: 33190

Elective and emergent total and partial colectomy

LAP colectomy is associated with a lower risk of severe complications and mortality than open colectomy

Wilson, 2014 [20]

Comparisons of incidence of postoperative complications between LAP and O colectomies

T: 37228

LAP: 15622

O: 21606

Elective and emergent total and partial colectomy

LAP colectomy with lower incidence of post-operative mortality and complications.

Risk factors associated with adverse post-operative outcomes change during the post-operative period; surveillance for these outcomes should be tailored by operative technique and phase of post-operative care.

Obesity is risk for complications following discharge for both LAP and O colectomies

Kannan, 2105 [21]

Comparison of outcomes between the LAP and O approaches for partial colectomy in patients aged 65 years and over

T: 22016 LAP: 12009

O:15595

Elective Partial Colectomy

LAP lower morbidity, shorter hospital LOS and decreased mortality

Schlussel, 2015 [22]

Comparison of techniques, for complex colorectal procedures

T: 45771

LAP study: 2946

LAP control 36,949

O: 5876

Elective total and partial colectomy

LAP for total abdominal and transverse colectomies has similar mortality rates and higher morbidity than other LAP colectomy procedures. LAP with improved perioperative outcomes when compared to Open

LAP: laparoscopic approach, O: open approach, T: total number. vs: versus, LOS: length of stay, ICU: intensive care unit

Table 3

Comparison of surgical techniques: robotic, laparoscopic, HALS, and open

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Dolejs, 2016 [23]

Comparison of outcomes between techniques

T: 27482 LAP: 25998. O: 1484

LAP vs robotic

Elective partial colectomy

Similar morbidity and mortality. Robotic shorter LOS and lower septic complications, but a higher rate of diverting ostomy (no clear reason)

Miller, 2016 [24]

Comparison of outcomes between techniques

T: 17774

LAP: 11267

R: 653

LAP vs robotic

Elective partial and total colectomy

Robotic increase operative time and shorter LOS. No differences between left, right colectomy and sigmoidectomy. No differences on mortality, anastomotic leak, reoperation, conversion, or readmission

Ezekian, 2016 [25]

Comparison of outcomes between techniques

T: 15976

LAP:15478

R:498

LAP vs robotic

Elective partial and total colectomy

Robotic and LAP with similar perioperative outcomes. Robotic with longer operative time.

Bahama, 2016 [26]

Comparison of outcomes between techniques, in abdomen vs pelvic procedures

T: 11477

LAP: 7790

R: 299

LAP vs robotic

Elective abdominal and pelvic colorectal surgery

Robotic with longer operative times, but lower conversion in pelvis and shorter LOS in pelvis and abdomen

Benlice, 2016 [27]

Comparison of outcomes between techniques

T: 1161

LAP: 387

O:387

LAP vs robotic vs O

Elective partial and total colectomy

Morbidity lower in LAP and robotic. Shorter hospital LOS in robotic

Moghadamyeghanenh, 2016 [28]

Comparison of outcomes for techniques, for total colectomies

T: 26721

LAP:9614

O: 16780 R: 326

LAP vs robotic vs O

Elective total colectomy

MIS is safe, with lower mortality and morbidity compared to O approach. Similar morbidity between LAP and Robotic. Robotic surgery lower conversion rate compared to LAP. Total hospital charges are significantly higher in robotic surgery compared to LAP

Papageorge, 2016 [29]

Comparison of outcomes between MIS and open surgery for colorectal cancer

T: 11031

MIS: 7200

O: 3831

MIS (LAP, HALS, SILS, robotic) vs O

Elective (partial or total is missing)

MIS lower morbidity, mortality, and shorter hospital LOS

Benilce, 2016 [30]

Comparison of outcomes between techniques

T: 3480

LAP: 1740

O: 1740

HALS vs O

Elective partial and total colectomy

HALS shorter hospital LOS, morbidity compared to open.

Benilce, 2016 [31]

Comparison of outcomes between techniques

T: 7843

LAP:4656

HALS: 3187

LAP vs HALS

Elective partial and total colectomy

LAP with slightly higher operative time. HALS with higher morbidity, SSI and ileus.

Moghadamyeghaneh, 2015 [32]

Comparison of outcomes between HALS, LAP and open colectomies

T: 21090

LAP 2860

O: 7480

HALS: 1999

HALS vs LAP vs O

Elective total and partial colectomy

HALS colectomy had a similar mortality and a lower morbidity compared to open. LAP had lower mortality and morbidity compared to open. Mortality similar for HALS and LAP; however, morbidity for HALS higher than LAP colectomy

LAP: laparoscopic approach, O: open approach, T: total number, vs: versus, LOS: hospital length of stay, MIS: minimally invasive surgery, HALS: hand-assisted laparoscopic surgery, SILS: single-incision laparoscopic surgery, SSI: surgical site infection

Laparoscopic versus open

Regarding the 10 articles comparing LAP versus open approach, five papers included only elective resections [13, 15, 17, 21, 22]; one contained only emergent procedures [14] and four papers incorporated both emergent and elective surgeries [16, 18, 19, 20]. According to type of resection, four papers contained only partial resections and six articles incorporated both total and partial resections. The general outcomes were similar in relation to lower morbidity and mortality, shorter length of hospital stay (LOS), and longer operative time for LAP technique; three papers [13, 14, 22] describe similar morbidity and mortality for specific situations such as emergent surgery, high-risk patients, and complex procedures (Table 2). It is important to underline that in two articles, the patients’ preoperative characteristics were similar for open and laparoscopic approach [13, 17]. Meanwhile in the other seven articles [14, 15, 16, 19, 20, 21, 22], issues such as mean age, American Society of Anesthesiologists (ASA) class, diabetes, cardiopulmonary, renal, vascular and neurological diseases, coagulopathies, and tobacco habits were in favor of laparoscopic surgery.

Laparoscopic versus robotic

All four articles analyzing LAP versus robotic techniques included only elective resections (Table 3). In regard to type of resection, Dolejs’ study [23] contained only partial resections, in contrast to Miller et al. [24], Ezequian et al. [25], and Bahama et al. [26] papers which incorporated both total and partial resections. The general outcomes were comparable with respect to morbidity and mortality, shorter LOS, and longer operative time for robotic technique compared to LAP approach. In relation to conversion rate, one paper by Miller et al. [24] reported comparable rates for both techniques; however, Bahama et al. [26] concluded that specifically for pelvic procedures, the conversion rate is lower using robotic technique. Additionally, Dolejs’ study [23] describes a higher rate on diverting ostomy for robotic approach.

Minimally invasive surgery (LAP, HALS, SILS, robotic) versus open

Three articles with elective resections that compared the outcomes of LAP, robotic, and open techniques were analyzed (Table 3). Moghadamyeghanenh et al. [28] included exclusively total colectomy; on the contrary, Benlice et al. [27] included both total and partial resections. One paper by Papageorge et al. [29] did not specify the type of resection (partial or total). Comparable outcomes were found in relation to lower morbidity and mortality for minimally invasive surgery (MIS) and shorter hospital LOS for robotic technique compared to open approach. Additionally, Moghadamyeghanenh et al. [28] described lower conversion rate and higher hospital costs for robotic compared to LAP approach. Analyzing articles in which open versus MIS were compared, baseline patients’ characteristics were similar in two studies [27, 30], while in three articles, differences such as age, diabetes, hypertension, cardiopulmonary and renal disease, coagulopathies, and ASA class were significantly worse in the patients who underwent open surgery [28, 29, 32].

HALS

Three papers with elective total and partial colectomies were included (Table 3). The HALS versus open paper by Benlice et al. [30] reported shorter LOS and lower morbidity in favor of HALS technique. Then Benlice’s HALS versus LAP approach article [31] showed lower morbidity but higher operative time for LAP technique. Finally, Moghadamyeghaneh et al. [30] included HALS, LAP, and open approaches; lower morbidity and similar mortality for HALS compared to open were shown, but higher morbidity and similar mortality than LAP technique were observed.

Specific types of colonic resections

Studies about specific types of colonic resections are displayed in Table 4. Regarding to abdominal perineal resection (APR), two papers were found, both comparing LAP versus open approach. Stewart et al. [33] in 2011 found similar short-term complications between LAP and open approaches, mortality was not reported, and no difference in operative time, LOS, and reoperation was observed. In contrast, Schlussel et al. [34] in 2015 reported lower morbidity (SSI and pulmonary complications) and shorter LOS for LAP APR. No significant difference was noted between the groups with respect to age, tobacco use, insulin-dependent diabetes steroid use, preoperative chemotherapy, and preoperative radiation therapy; only a slight difference favoring the laparoscopic group with tendency to normal weight and lower obesity rate in the first study [33]; similarly, younger patients and lower rates of hypertension and metastatic cancer were included in the laparoscopic group in the second study [34].
Table 4

Comparison of specific types of colectomy: total colectomy and ileorecto anastomosis, proctectomy, abdomino perineal resection, reversal of Hartmann’s procedure

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Stewart, 2011 [33]

Comparison of outcomes between LAP and open APR resection for rectal cancer and to identify factors associated with the choice of either approach

T: 1340

LAP: 143

O: 1197

LAP vs O

Abdomino perineal resection

Short-term complication rates between LAP and open APR are similar. No difference in LOS, operative time, and reoperation.

Surgeon preference (and not patient factors) serves as the principal impetus in choosing between LAP and open surgery (the strong preference is still in favor of O)

Schlussel, 2015 [34]

Comparison of outcomes between techniques LAP and open for APR

T: 3191

LAP: 1019

O: 2172

LAP vs O

Abdomino perineal resection

Mortality was similar in LAP vs O. LAP surgery with lower morbidity (in SSI and pulmonary complications) and shorter LOS

Greenblatt, 2011 [35]

Comparison of techniques, for proctectomy in rectal cancer

T: 5420

LAP: 1040

O: 4380

LAP vs O

Elective proctectomy for rectal cancer

LAP proctectomy shorter LOS and lower 30-day morbidity compared to open

Arkenbosch, 2014 [36]

Comparison of outcomes after LAP and open approach for reversal of Hartmann’s procedure

T: 4148

LAP 732

O: 3416

LAP vs O

Elective reversal of Hartmann’s procedure

LAP with lower postoperative morbidity and a shorter LOS

Young, 2015 [37]

Comparison of risk adjusted morbidity between LAP, open abdominal and perineal approach for rectal prolapse.

T: 3254

LAP: 729

O: 966

Perineal: 1559

LAP vs O vs perineal

Elective partial surgery for rectal prolapse

LAP rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. Mortality was lower after LAP and abdominal procedures compared the perineal group

Onder, 2016 [38]

Comparison of outcomes between techniques in elective TC and IRA

T: 652

LAP: 326

O:326

LAP vs O

Elective TC and IRA

LAP shorter hospital LOS but longer operative time than open. Postoperative 30-day morbidity is similar

Nfonsam, 2016 [39]

Comparison of complications between right-sided and left-sided LAP colectomies for cancer

T: 2512 (1256 each group)

LAP left and right colectomies with anastomosis

Elective partial right and left colectomy

Left LAP colectomy with higher SSI rates, higher incidence of ureteral injury and a longer hospital LOS compared to right LAP colectomy. Similar 30-days overall morbidity and mortality

TC+ IRA: total colectomy and Ileorecto anastomosis, APR: abdomino-perineal resection, LAP: laparoscopic approach, O: open approach, LOS: hospital length of stay, SSI: surgical site infection, T: total number, vs: versus

One article by Greenblatt et al. [35] comparing surgical techniques for rectal cancer reported that LAP proctectomy had shorter LOS and lower morbidity compared to open technique; no significant differences for any of the preoperative factors (age, comorbidities, ASA class) between the LAP and open resection groups were found.

Outcomes after LAP and open approach for reversal of Hartmann’s procedure were analyzed by Arkenbosch et al. [36], and the conclusion favored LAP approach with lower postoperative morbidity and a shorter LOS. Additionally, no significant differences for any of the preoperative factors (age, comorbidities, use of steroids, ASA class) between the LAP and open resection groups were found, except for higher rate of dyspnea and slightly higher BMI for the open group.

In relation to rectal prolapse, one paper by Young et al. [37] compared morbidity between LAP, open abdominal, and perineal approach for rectal prolapse; LAP rectal prolapse surgery has comparable morbidity and mortality to perineal surgery; however, mortality was lower after LAP and abdominal procedures compared the perineal group. The rate of steroid use and comorbidities (hypertension, COPD, congestive heart failure), in this paper, were significantly higher in patients undergoing perineal approach compared to laparoscopic and open surgeries.

Elective total colectomy and ileorecto anastomosis (TC and IRA) were evaluated in Onders’ paper [38], and the comparison of techniques found similar morbidity between LAP and open TC and IRA; in addition, LAP approach had shorter LOS but longer operative time than open technique. This is a case-matched design using data procedure-targeted database, then no statistically significant differences were found, just a higher rate of ascites and preoperative weight loss for the open group.

Finally, LAP elective partial right and left colectomy for patients with colon cancer were compared by Nfonsam et al. [39], and similar overall morbidity and mortality were demonstrated; nevertheless, left LAP colectomy had higher SSI rates, higher incidence of ureteral injury, and a longer LOS compared to right LAP colectomy. The two groups were matched using propensity score matching for demographics, previous abdominal surgery, preoperative chemotherapy and radiotherapy, and preoperative laboratory data.

Specific disease-related outcomes

Inflammatory bowel disease

Three papers explored outcomes for LAP versus open partial colectomy in patients with Crohn’s disease in emergent and elective surgeries. Lesperance et al. [40] and Lee et al. [42] reported a benefit of LAP approach with lower morbidity and shorter LOS compared to open. In contrast, Kirat’s paper [41] concluded comparable outcomes between LAP and open approach. Regarding patients’ selection for laparoscopic approach, in Lesperance’s study [40], patients included were younger, age < 35, female, admitted to a teaching hospital, ileocecal location, and lower disease stage. Moreover, Lee [42] found that significant differences in outcomes for the two surgical groups persist despite the selection bias towards the use of laparoscopy for younger and healthier patients. Meanwhile, patients included in Kirat’s article [41] had no statistically significant difference in age, body mass index (BMI), smoking, use of steroids, diabetes mellitus, and ASA class.

Ulcerative colitis (UC) surgery trends and outcomes were exposed in Causey’s study [43] including total and partial colectomy in elective and emergent settings. LAP approach for UC reported an increase of use each year; additionally, lower morbidity and mortality were observed, even in more complex procedures, such as total abdominal colectomy and ileal pouch-anal anastomosis (TAC and IPAA) (Table 5).
Table 5

Crohn’s disease, diverticular disease, ulcerative colitis, and obesity

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Lesperance, 2009 [40]

Examination of use and outcomes of LAP approach for Crohn’s disease on a national level

T: 49609

LAP: 2826

O: 46783

Lap vs O

Partial elective and emergent colectomy

LAP resection with lower morbidity, shorter LOS, lower charges, and mortality. Open surgery was used more often for fistulas and when ostomies were required. Independent predictors of utilization of LAP resection were age < 35, female gender, admission to a teaching hospital, ileocecal location, and lower disease stage. Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative method

Kirat, 2010 [41]

Compare outcomes after LAP versus open ileocolic resections for Crohn’s disease

T:307

LAP: 104

O: 203

LAP vs O

Elective and emergency ileocolic resection.

LAP surgery with comparable complications to open approach, and shorter hospital LOS.

Lee, 2012 [42]

Impact of the operative approach on outcomes after ileocolic resection for Crohn’s disease

T: 1917

LAP: 644

O: 1273

LAP vs O

Elective and emergency ileocolic resection.

LAP surgery with lower rate complications and shorter LOS compared to open.

Causey, 2013 [43]

Comparison of outcomes between LAP and open colectomy for ulcerative colitis (UC)

T: 1077

LAP: 342

O: 735

LAP vs O

Elective and emergent total and partial colectomy

LAP approach for UC with lower morbidity and mortality, even in more complex procedures, such as TC and IPAA

Masoomi, 2011 [44]

Evaluation of the difference in outcomes between elective LAP vs open colectomy with anastomosis for diverticulitis

T: 124734

LAP: 14562

O: 110172

LAP vs O

Elective partial colectomy

LAP with lower morbidity, mortality, shorter Hospital LOS, and lower hospital charges compared to the open approach

Kakarla, 2012 [45]

Comparison of outcomes for LAP vs open colectomy in symptomatic diverticulosis

T: 7629

LAP: 3759

O: 3870

LAP vs O

Elective partial colectomy

LAP approach with lower morbidity and similar mortality compared to open

Mbadiwe, 2013 [46]

Comparison of outcomes between LAP and open colectomy forcomplicated diverticulitis

T: 11981

LAP: 5432

O: 6639

LAP vs O

Elective and emergent partial colectomy

LAP approach with lower morbidity for colectomy and primary anastomosis in diverticulitis. Mortality rate was similar

Schlussel, 2016 [47]

Description of clinical features of patients undergoing both a LAP and open surgery for right-sided diverticulitis

T: 2233

LAP: 592

O: 1641

LAP vs O

Elective and emergent right hemicolectomy or ileocecectomy

Safety and efficacy of a LAP approach. Overall morbidity and in-hospital mortality were significantly less in the LAP compared to open group. Hospital LOS was shorter by two and half days for LAP

Mustain, 2012 [48]

Determination of the impact of obesity in LAP colectomy

T: 9693 (all LAP)

LAP

Elective total and partial colectomy

Obesity is an independent factor for complications in LAP colectomy

T: total number of patients, LAP: laparoscopic approach, O: open approach, T: total number. LOS: hospital length of stay, UC: ulcerative colitis, TC and IPAA: total abdominal colectomy and ileal pouch anal anastomosis, vs: versus

Diverticular disease and obesity

Outcomes for diverticular disease were explored in four different papers comparing LAP versus open approach. Masoomi et al. [44] and Kakarla’s article [45] included patients with elective partial colectomy. Then, Mbadiwe [46] included patients with elective and emergent partial colectomy. Also, Schlussel’s article [47] explored trends on right hemicolectomies and ileocecectomies for right-sided diverticulitis. Kakarla’s paper reported lower morbidity and similar mortality rate between LAP and open surgery, whereas the other three studies concluded that LAP colectomy for diverticular disease had lower morbidity and mortality compared to open approach. Additionally, Masoomi et al. and Schlussel et al. displayed other advantages of LAP surgery such as lower mortality and costs and shorter LOS.

Interestingly, the open-group patients in three studies [44, 45, 47] were statistically significantly older and had higher comorbidities (hypertension, diabetes mellitus, chronic lung disease, cardiac diseases) [44, 45, 47].

The impact of obesity in LAP colectomy was examined in one paper by Mustain [48] that included LAP elective total and partial colectomy. This study demonstrated obesity as an independent factor for complications in LAP colectomy. Furthermore, significant differences between BMI classes were found in regard to age, sex, ASA class, and preoperative diagnosis.

Preparatory outcomes: conversion, reoperation, readmission, hospital length of stay

Conversion

Regarding to conversion of LAP to open colorectal surgeries, two papers were found. Bahama et al. [49] included patients with elective partial and total colorectal resections and identified the following risk factors for conversion: age (over 50), BMI (obese and underweight), ASA classes 3 and 4, smoking, ascites, and weight loss (Table 6). Moghadamyeghanenh et al. [50] included patients with elective and emergency total and partial colorectal resections and assessed the outcomes of patients with conversion from LAP to open. Higher morbidity, mortality, LOS, and costs were observed on the conversion group compared to LAP technique group; additionally, higher rate of surgical site infection (SSI) in conversion group was reported, compared with LAP and open technique. Proctectomy was reported with the highest rate of conversion compared to other types of resection (Table 6).
Table 6

Perioperatory related outcomes: conversion, reoperation, readmission, length of hospital stay

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Conversion

 Bahama, 2015 [49]

Identification of factors associated with risk of conversion from LAP to open colorectal resection

T: 44093

LAP: 4158

Converted: 2508

LAP

Elective partial and total colectomy

Multiple risk factors for conversion were found: age over 50, obese and underweight, ASA class 3 and 4, smoking, ascites and weight loss. Novel finding: underweight patient

 Moghadamyeghanenh, 2014 [50]

Assessment of outcomes of patients who underwent conversion of LAP to open colorectal resection

T: 776007

LAP: 289468

O:438275

Converted: 48264

LAP

Elective and emergency partial and total colectomy

Conversion group has higher morbidity, mortality, hospital stay and cost compared to laparoscopic. SSI higher in conversion compared with LAP and open. Proctectomy with highest rate of conversion.

Reoperation

 Speicher, 2014 [51]

Determination of the impact of LAP approach on rate of reoperation after elective segmental colectomy

T: 39063

LAP: 23177

O:15886

LAP vs O

Elective partial colectomy

In elective segmental colorectal surgery, LAP approach has similar risk of reoperation

Readmission

 Esemuede, 2015 [52]

Comparison of the risk of readmission after LAP vs open colorectal surgery

T: 30428

LAP: 12239

O: 18189

LAP vs O

Elective and emergency partial and total colectomy

Risk of readmission is higher with proctectomy vs colectomy; however, lower with LAP surgery for both. LAP surgery with less incidence of complications (SSI, bleeding, re-operation, mortality)

Length of hospital stay

 Stefanou, 2012 [53]

Demonstration of an independent improvement in LOS for LAP colectomy

T: 45645

L: 12455

O: 33190

LAP vs O

Elective and emergent total and partial colectomy

LAP colectomy independently decreases LOS compared with open colectomy

LAP: laparoscopic approach, O: open approach, LOS: length of hospital stay, T: total number, vs: versus, SSI: surgical site infection

Reoperation

The impact of surgical technique in the rate of reoperation was documented in Speicher’s article [51] that included elective partial colorectal resection; in this paper, there was no a statistically significant difference in odds of return to the operating room for LAP versus open surgical approach. Nevertheless, statistically significant differences were observed regarding the preoperative patients’ comorbidities. In fact, older patients, diabetes, cardiopulmonary disease, coagulopathies, as well as ASA class and preoperative radio and chemotherapy were observed more frequently in patients who underwent open surgery (Table 6).

Readmission

The risk of readmission related to the LAP vs open techniques was reported by Esemuede et al. [52], in a study with elective and emergency surgery for partial and total colorectal resections. LAP surgery showed lower risk of remission for all types of resection; additionally, proctectomy had higher risk of readmission than other types of colectomy. In this article, several preoperative negative factors were also observed in patients who underwent open surgery (Table 6).

Length of hospital stay

One paper by Stefanou et al. [53] included elective and emergent total and partial colectomies and established that LAP colectomy independently decreases LOS if compared with open colectomy. Statistical methods to control selection bias of patients who might be more “surgically fit” were applied for that study (Table 6).

Morbidity: surgical site infection, anastomotic leak, pulmonary complications, splenic injuries, and venous thromboembolism

Surgical site infection

The impact of LAP technique on the incidence SSI was studied on two papers; both compared LAP versus open approach; total and partial colorectal resections were included. Aimaq’s study [54] exposed an incidence of SSI of 9.37% for LAP technique versus 15.7% for open technique. Kiran’s paper [55] reported a SSI of 9.5% for LAP technique versus 16% for open technique. Elective and emergency resections were performed in Kiran’s paper; in contrast, this data was not documented in Aimaq’s study. In both studies, higher ASA class and older patients for the open surgery group were reported; additionally, a significant reduction on SSI rate for LAP versus open approach was observed (Table 7).
Table 7

Morbidity: surgical site infection, anastomotic leak, pulmonary complications, splenic injuries, and venous thromboembolism

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Surgical site infection

 Aimaq, 2011 [54]

Assessment the role of LAP surgery in reduction of SSI rates in colorectal surgery

T: 23939

LAP:7755

O: 16184

LAP vs O

Total and partial colectomy (elective or emergency not documented)

LAP colorectal surgery with lower incidence of SSI (9.37%)compared to open approach (15.7%)

 Kiran, 2010 [55]

Comparison of SSI rates between LAP and open colorectal surgery

T: 10979

LAP:3414

O:7565

LAP vs O

Elective and emergency partial and total colectomy

SSI rate was 9.5% for LAP vs 16.1% for open surgery. LAP approach is independently associated with a reduced SSI when compared with open surgery

Risk of anastomotic leak

 Murray, 2016 [56]

Assessment the Risk of anastomotic leak 30 days after LAP versus open elective colorectal resection

T: 23568

LAP:15256

O: 8312

LAP vs O

Elective partial and total colectomy

LAP colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy. Patients who underwent LAP were younger and with fewer comorbidities

Pulmonary complications

 Owen, 2013 [57]

Evaluation of the impact of operative time on PPC following LAP versus open colectomy

T: 25419

LAP13741

O: 11678

LAP vs O

Elective total and partial colectomy

Operative time is independently associated with increased risk of PPC in patients with both LAP and open colectomy. However, LAP with half the absolute risk of PPC

Risk of incidental splenic injury

 Isik, 2015 [58]

Evaluation of LAP surgery in the risk reduction of incidental splenic procedures during colorectal surgery

T: 93633

LAP:37870

O: 55763

LAP vs O

Elective and emergency partial and total colectomy

LAP surgery with lower rate of incidental splenic procedures during colorectal surgery

Venous thromboembolism

 Buchberg, 2011 [59]

Comparison of incidences and to highlight the risk factors of developing VTE after LAP vs open colorectal surgery

T: 149304

LAP: 7848

O: 141456

LAP vs O

Elective and emergency partial and total colectomy

Incidence of perioperative VTE is lower after LAP compared to open surgery. Patients with IBD and proctectomy reported the highest incidence of VTE

 Shapiro, 2011 [60]

Assessment of the risk of VTE after major colorectal procedures. The influences of LAP versus open approaches on VTE were compared

T: 31109

L: 8966

O: 22143

Lap vs O

Elective and emergent total and partial colectomy

LAP approach with a lower VTE rate in comparison with open surgery. This additional benefit of the minimally invasive approach further supports its use, whenever feasible, for a variety of colorectal conditions

LAP: laparoscopic approach, O: open approach, T: total number, vs: versus, LOS: hospital length of stay, PPC: postoperative pulmonary complications, IBD: inflammatory bowel disease, VTE: venous thromboembolism, SSI: surgical site infection

Anastomotic leak

The study by Murray et al. [56] determined the risk of anastomotic leak regarding the surgical technique. Patients with elective surgery, for partial and total colorectal resections, were included; LAP colectomy was associated with reduced odds of developing an anastomotic leak following colectomy. Patients who underwent laparoscopy were younger and with fewer comorbidities (Table 7).

Pulmonary complications

Evaluation of postoperative pulmonary complications (PPC) between LAP and open colectomies was performed in a study by Owen et al. [57]. Patients with elective total and partial colectomies were included, and the results showed that operative time was independently associated with increased risk of PPC in patients for both LAP and open colectomy. However, LAP approach had half the absolute risk of PPC; therefore, when safe, it should be preferentially utilized despite a potential for prolonged operative duration (Table 7). Anyway, preoperative differences in patients’ age and ASA class were reported.

Incidental splenic injuries

In relation to incidental splenic injuries during LAP colorectal procedures, one article by Isik et al. [58] examined patients with elective and emergent surgery, for partial and total colorectal resection; a lower rate of incidental splenic procedures was reported, during LAP colorectal compared to open approach (Table 7).

Venous thromboembolism

Two papers related to venous thromboembolism (VTE) and LAP colorectal surgery were found. The first by Buchberg et al. [59] explained the incidence and risk factors of VTE for LAP colorectal surgery. That study included patients with both elective or emergency surgeries, for partial and total colorectal resection; the incidence of perioperative VTE is lower after LAP compared to open surgery. Patients with inflammatory bowel disease (IBD) and proctectomy reported the highest incidence of VTE. Obesity, congestive heart failure, malignancy, chronic pulmonary disease, pulmonary circulation disorders, and IBD were identified as statistically significant risk factors for VTE (Table 7). Additionally, Shapiro’s article [60] included patients with elective and emergent total and partial colectomies and ratified a lower incidence of VTE for LAP compared to open surgery. In both studies, preoperative factors such as higher age and ASA class, and comorbidities were observed more frequently in the open group.

Sociodemographic outcomes and academic issues

Sociodemographic and economic

Sociodemographic and economic results were studied in seven papers (Table 8). First, regarding the disparities between use of MIS, Robinson et al. [62] and Alnasser et al. [65] demonstrated that race was not a factor for selection of MIS; however, some factors such as high income, private insurance, and hospital type (teaching, high volume, and urban) increased the likelihood of the use of LAP colectomy. Furthermore, one study by Singla et al. [63] demonstrated that hospital volume (HV) is a determining factor for the use of LAP approach; therefore, in this study, high volume hospitals were associated with increase probability of the use of LAP colectomy. In addition, a study by Bardakcioglu et al. [64] exposed a marked increase in the rate of LAP colectomy from 1996 to 2009, with more likelihood of this approach in Urban and teaching hospitals, and less probability if age was above 80, African American race, Medicaid, and self-pay insurance.
Table 8

Sociodemographic outcomes and academic training impact

Author, year

Aim

Number of patients

Approach

Type of surgery

Outcomes

Sociodemographic and economic-related outcomes

 Singla, 2010 [61]

To investigate whether hospital volume is a factor determining the use of LAP colectomy

T: 209769

LAP: 8407

O: 201362

LAP vs O

Elective and emergent total and partial colectomy

HVH are associated with an increased likelihood that colectomy will be performed with LAP

 Robinson, 2012 [62]

Determination of ethnic and socioeconomic disparities in the use of MIS for colorectal disease at HVH

T: 211862

MIS:16637

O: 195225)

MIS vs O

Elective and emergent total and partial colectomy

MIS more likely in patients within the highest income and private insurance (vs Medicaid and uninsured). Race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH

 Shaligram, 2013 [63]

Examination of the influence of LAP vs open approach, to the discharge to a skilled care facility

T: 221294

LAP: 70361

O: 150933

LAP vs O

Elective and emergent total and partial colectomy

LAP colectomy has a decreased likelihood of discharge to skilled care facilities.

When feasible, the LAP should be considered as an option, especially in elderly patients because it may reduce their likelihood of discharge to a skilled care facility

 Bardakcioglu, 2013 [64]

Determination of the growth pattern and current rate of LAP partial colectomy in the USA and analyze various factors that influence the adaptation rate over time

T: 226585

LAP:26547

O: 200038

LAP vs O

Partial colectomy (elective or emergency was not reported)

A marked increase in the rate of LAP colectomy is seen from 1996 to 2009. Significant socioeconomic differences in access to MIS persist (more likely: Urban and teaching hospitals, less likely: age above 80, African American race, Medicaid and self-pay insurance). LAP approach seems to be increasingly used in non-teaching hospitals

 Alnasser, 2014 [65]

Comparison of rates of LAP colorectal cancer surgery, according to race, insurance status, geographic location, and hospital size

T: 14502

LAP:4691

O: 9811

LAP vs O

Elective and emergency partial and total colectomy for colorectal cancer

Race was not a factor for selection of LAP technique. Significant differences in the selection of LAP were observed, based on: insurance status, geographic location, and hospital type. The highest probabilities of receiving LAP procedures on patients covered by private insurers, at teaching and urban hospitals and living on southern region of the country

 Lassiter, 2016 [66]

Analysis of the relationship between race, socioeconomic status and the use of LAP to address diverticulitis

T: 53054

LAP: 22070

O: 30983

LAP vs O

Elective and emergent partial colectomy

Measurable differences in the surgical management of diverticulitis by race and socioeconomic status. Black patients, low household income, less than private insurance with lower odds of undergoing a LAP colectomy for diverticulitis

 Vaid, 2012 [67]

Analysis of the cost differences and to assess the use of LAP and open colectomy in colon cancer

T:63950

LAP: 5147

O: 58802

LAP vs O

Elective and partial colectomy

LAP colectomy is not more expensive than open colectomy and also offers the advantage of lower postoperative complications, which can contribute to cost saving. The use of LAP is increasing but it is still performed in a minority of cases

Academic training impact

 Sippey, 2015 [68]

Evaluation of the effect of resident involvement on LAP vs open colectomy for cancer

T: 37330

LAP: 13965

O: 23365

LAP vs O

Elective (partial or total is missing)

Association of resident operative involvement with higher rates of morbidity and lower mortality in oncology patients undergoing LAP and open colectomy

LAP: laparoscopic approach, O: open approach, T: total number, vs: versus, LOS: length of hospital stay, MIS: minimally invasive surgery, HVH: high-volume hospitals, USA: United States of America

An analysis of the relationship between race, socioeconomic status, and the use of LAP approach to address diverticulitis was achieved in Lassiter’s article [66], where patients with elective and emergent partial colectomy were included and differences in the surgical management by race and socioeconomic status were reported. Black patients, low household income, and less than private insurance had lower odds of undergoing a LAP colectomy for diverticulitis.

The study by Shaligram et al. [63] showed a decreased likelihood of discharge to skilled care facilities with LAP colectomy.

Evaluation of cost differences between LAP and open colectomy was performed by Vaid et al. [67] in a study with 63,950 patients, where only 2% received LAP approach. They concluded that LAP colectomy is not more expensive than open and also offers the advantage of lower postoperative complications, which can contribute to cost saving.

Academic training impact

The influence of resident involvement in surgical outcomes was investigated by Sippey et al. [68]. Patients with elective colectomies were included, and an association of resident operative involvement with higher rates of morbidity and lower mortality in oncology patients undergoing both LAP and open colectomy was reported (Table 8).

Discussion

Big databases such as NSQIP and NIS were essentially created for quality improvement and for billing and reimbursement purposes [69]. It is fundamental to explain the difference between the clinical databases (ACS-NSQIP) and the administrative databases (NIS) [5, 7]. Clinical databases are focused on recollection of data about patients who undergo surgery by the participating institutions. A fulltime nurse or a trained data expert specifically skilled on NSQIP methods and data field definitions collects and includes information about sociodemographic data, clinical and laboratory outcomes, preoperative, intraoperative data, and data about 30 days results after surgery, such as postoperative complications and mortality [3, 5, 7]. In the case of administrative databases, such as NIS, the main goal is to obtain information useful for administrating healthcare; therefore, less clinical data about gender, age, diagnosis, and surgery are recorded [3, 7]. For those reasons, the nature and objective of the information recorded in the two different types of databases could result in a qualitative variation between data collected, which could lead into bias for the present review.

Additionally, another bias for this review is the selection of patients included in the studies. Therefore, in some of the included studies, minimally invasive procedures might suggest advantages over the open surgery because patients selected have more favorable preoperative characteristics.

In this manner, colorectal surgery papers account for just a small part of those large databases; among the 1374 papers with “NSQIP” and 5847 with “NIS” appearing in a PubMed search through up to February 2017, just around 300 papers are related to laparoscopic colorectal surgery.

In spite of the tiny representation of our aim in those mentioned databases, the results of this systematic review exposed that current leading areas of interest in laparoscopic colorectal surgery according to NSQIP and NIS articles are: perioperative and morbidity-related outcomes, comparison between different surgical techniques, specific disease-related results sociodemographic disparities, and academic training impact issues.

Limitations for NSQIP and NIS databases regarding long-term outcomes are present, because of the nature of those databases showing only 30-day results and hospitalized outcomes [69]. Therefore, there is a lack of data supporting longer-term outcomes (as those of oncologic safety in cancer patients) and some outpatient complications. Moreover, information contained in those databases and utilized for the scientific articles could had been exposed to bias such as coding error and deficient information retrieval. Furthermore, a meta-analysis based on the papers could not be performed because all patients included in the articles come from the same databases. However, in Fig. 2, an overview of the main topic and confrontation between results of different approaches is reported; interestingly, most papers support the superiority or non-inferiority of MIS over open in colorectal surgery field.
Fig. 2

Overview of general results of comparison between surgical techniques. Lap: laparoscopic. MIS: minimally invasive surgery. HALS: hand-assisted laparoscopic surgery. IBD: inflammatory bowel disease

Fundamental advantages of the use of big databases were learned with this research. For instance, data obtained from risk-adjusted databases permits comparisons of patients with similar characteristics which leads to more reliable outcomes and allows the external validation of criteria obtained from strong evidence-based medicine studies (such as RCT), by collecting outcomes from this type of trial when applied in larger and non-controlled populations; therefore, evaluating its applicability in the “real world” [70]. Additionally, those databases facilitate the analysis of clinical aspects that could not be planned in a RCT (for example a populations that meet the characteristics for a study). Comparisons between main topics reported in this review from big data and the existence of RCT related is shown in Table 9.
Table 9

Articles from big databases (ACS-NSQIP and NIS) according to main topic and respective randomized clinical trial related

Main topic

Papers in this review

Randomized clinical trial related

Comparison between robotic versus LAP approach

Dolejs, 2016 [23]

Miller, 2016 [24]

Ezekian,2016 [25]

Bahama, 2016 [26]

Moghadamyeghanenh, 2016 [28]

Papageorge, 2016 [29]

Jayne, 2017 [74]

Comparison between HALS versus LAP approach

Benilce, 2016 [31]

Moghadamyeghaneh, 2015 [32]

Targarona, 2002 [75]

Marcello, 2008 [76]

Comparison between LAP versus open rectal cancer surgery

Stewart, 2011 [33]

Ng, 2008 [78]

Comparison between LAP and open approach for reversal of Hartmann’s procedure

Arkenbosch, 2014 [36]

Not found

Comparison between LAP, open abdominal and perineal approach for rectal prolapse

Young, 2015 [37]

Not found

LAP versus open total colectomy and ileorectal anastomosis

Onder, 2016 [38]

Not found

Right-sided and left-sided LAP colectomies for cancer

Nfonsam, 2016 [39]

Not found

LAP versus open Crohn’s disease surgery

Lesperance, 2009 [40]

Kirat, 2010 [41]

Lee, 2012 [42]

Maartense, 2006 [81]

LAP versus open surgery for Ulcerative colitis

Causey, 2013 [43]

Not found

LAP versus open surgery for diverticular disease

Mbadiwe, 2013 [46]

Schlussel, 2016 [47]

Klarenbeek, 2009 [84]

Perioperatory related outcomes: conversion, reoperation, readmission

Bahama, 2015 [49]

Moghadamyeghanenh, 2014 [50]

Speicher, 2014 [51]

Esemuede, 2015 [52]

Stefanou, 2012 [53]

Not found for those specific end points

Sociodemographic and economic-related outcomes

Singla, 2010 [61]

Robinson, 2012 [62]

Shaligram, 2013 [63]

Bardakcioglu, 2013 [64]

Alnasser, 2014 [65]

Lassiter, 2016 [66]

Vaid, 2012 [67]

Not found for those specific end points

Academic training impact

Sippey, 2015 [68]

Not found for those specific end points

LAP: laparoscopic, HALS: hand-assisted laparoscopic surgery

Furthermore, some events such as a drug efficacy or adverse effects, surgery positive outcomes, or complications could be identify and help to implement or avoid an specific procedure or medication quicker and easier [70]. Likewise, the large number of patients from all the articles included in the present review (a total of 2,972,807 patients) confirms the previously mentioned points and enables an external comparison and validation of other studies [3]. These benefits of big databases help to improve the quality and results of healthcare [71].

Interestingly, in our review, most papers were focused on comparison between surgical techniques. This way, short-term benefits were observed for LAP vs open colectomy such as lower morbidity, mortality and shorter LOS and similar outcomes for emergent surgery, high-risk patients, and complex procedures. These results are in agreement with a Cochrane systematic review [72] for colorectal resections and a meta-analysis [73] for colorectal cancer, documenting evidences to support LAP procedures with advantages as a shorter LOS and a lower surgical morbidity rate.

Despite the existing high expectative on robotic surgery, its possible advantages over LAP approach in our review are still controversial; consistently, findings of the RCT ROLARR [74] suggest that robotic-assisted laparoscopic surgery, when performed by surgeons with varying experience with robotic surgery, does not confer an advantage in rectal cancer resection. A different scenario for HALS colectomy was contemplated, because articles for the present review displayed advantages over open approach in terms of morbidity and LOS; although benefit of HALS over LAP approach was not clearly established; a previous prospective RCT by Targarona et al. [75] and Marcelo et al. [76] demonstrated that HALS had outcomes, costs, and oncologic features comparable to LAP. Therefore, we agree with those authors that HALS should be considered as a useful adjunct when difficult situations and non-experience surgeons.

Benefits of MIS over open colectomy were also found, in concordance with a systematic review by Noel et al. [77], where advantages in short-term outcomes and shorter LOS were reported; furthermore, this author demonstrated consistent finding across colorectal condition (colorectal cancer, IBD, diverticular disease) and study type (RCT versus other study designs).

Another fundamental benefit of big data is the quantity of information from several centers that facilitates the analysis of low prevalent aspects or diseases which otherwise; it would have been impossible or it might take many years to obtain. For example, in specific types of resection, LAP showed comparable outcomes for APR, rectal prolapse surgery, and TC with IRA compared to open approach. In the same manner, advantage of LAP proctectomy for rectal cancer was exposed; in contrast, a RCT by Ng et al. [78] for rectal cancer also reports similar morbidity and mortality between LAP and open APR; nevertheless, a benefit of faster postoperative recovery was seen. With respect to LAP versus open APR for rectal cancer, discrepancies between papers by Stewarts in 2011 [33] with similar outcomes and Schlussel in 2015 [34] with lower morbidity for LAP were observed. We hypothesized this could be attributed to the learning curve and increase in the experience and use of LAP approach through the years. Additionally, a RCT by Ng et al. [78] for rectal cancer also reports similar morbidity and mortality between LAP and open APR; however, a benefit of postoperative recovery was seen. Because of the nature of the short-term results of the big databases included in our review, long-term outcomes such as those shown on RCT Bonjer et al. COLOR II [79] and Jackson et al. [80] related to oncologic safety of LAP surgery for rectal cancer were not found.

Laparoscopic approach for Crohn’s disease reported controverted results for morbidity; meanwhile, LOS was shorter. However, the existing literature supports the benefits of LAP approach, such as the RCT reported by Maartense in 2006 [81] with lower morbidity, mortality, LOS and costs for the LAP group, and a more recent meta-analysis in 2013 by Patel et al. [82] with decreased perioperative complications in the LAP group.

On the other hand, the article analyzing LAP colectomy for UC reported lower morbidity and mortality [40], in disagreement with a Cochrane review including UC and FAP with no difference in morbidity and mortality for the LAP and open groups [83].

Surgery for diverticulitis seems to have benefits of lower morbidity, mortality, and costs in our review if LAP approach is performed; those results are in agreement with RCT Sigma trial [84] where LAP sigmoidectomy for diverticulitis exposed a reduction in major complications and shorter LOS compared to open approach.

Big databases play a paramount role in the identification of risk factor predictors for specific interventions. In our review, perioperative outcomes such as readmission, LOS, and conversion appear to have advantages if LAP colectomy is performed, whereas reoperation rate demonstrated to have no difference related to the surgical technique. Some benefits on lower complications with LAP colectomy were observed in the present review; specifically, in SSI, anastomotic leak, pulmonary complications, VTE, and incidental splenic injuries. Some of those results are in concordance with a systematic review of the literature with meta-analysis by Schwenk et al. [72] that evidenced certain advantages for the LAP colectomy: shorter LOS, decrease surgical morbidity, and lower surgical wound infection rate with no difference in intraabdominal abscesses; on the other hand, the same study exposed no significant difference in relation to reoperation, pulmonary complications, VTE, anastomotic leakage, and mortality. This discrepancy of results could be attributed to the heterogeneity of the articles included in both studies.

A crucial target of big databases is the sociodemographic and economic disparities in the use of certain technologies which allows the evaluation and future modification of national and worldwide healthcare policies. For instance, this review showed the disparities in the use of LAP colectomy and it was exposed the influence of age, race, type of insurance, patient income, and type of hospital (urban, high volume and teaching) in the preference of use of MIS. Interestingly, an article in our review described higher morbidity with resident participation in LAP colectomy [68]. The recognition of those factors is imperative for healthcare authorities in order to establish strategies with the main goal of decrease those disparities and improve patient’s care.

In conclusion, large databases such as NSQIP and NIS are just a small part of the potential application of Big Data technology and analysis in MIS; the information is useful and important as a complement for evidence-based medicine, providing priceless help monitoring its implementation in different clinical scenarios (external validation). Those large databases are a platform to establish benchmarks to measure the quality of patient care and to perform comparisons between diverse hospitals. Additionally, the outcomes from databases facilitate the analysis of low prevalent diseases and help to conduct and translate research to inform decision-making and improve healthcare delivery. A productive future for Big Data is presumed in different areas related to MIS, for instance: operating room control and monitoring, image-based advances in MIS (Indyocianine green, virtual reality), robotic and artificial intelligence, precision, and personalized surgery.

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.General and Digestive Surgery Unit, Hospital de la Santa Creu i Sant PauUAB Universidad Autónoma de BarcelonaBarcelonaSpain
  2. 2.Surgical Oncology Unit, Department of Hemato-Oncology, Hospital Dr. Rafael A. Calderón GuardiaCaja Costarricense del Seguro SocialSan JoséCosta Rica
  3. 3.Department of General Surgery and Surgical Specialties “Paride Stefanini”Sapienza, University of RomeRomeItaly

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