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Comparison of Laparoscopic vs Open Sigmoid Colectomy for Benign and Malignant Disease at Academic Medical Centers

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Few studies have examined outcomes of laparoscopic and open sigmoid colectomy performed at US academic centers. Using ICD-9 diagnosis and procedural codes, data was obtained from the University HealthSystem Consortium (UHC) Clinical Database of 10,603 patients who underwent laparoscopic or open sigmoid colectomy for benign and malignant disease between 2003–2006. A total of 1,092 patients (10.3%) underwent laparoscopic sigmoid colectomy. Laparoscopic sigmoid colectomy was associated with a significantly shorter length of stay (5.4 vs 7.4 days), lower overall complication rate (19.7 vs 26.0%), lower 30-day readmission rate (3.4 vs 4.6), and a lower hospital cost ($13,814 vs $15,626). When a subset analysis of malignant and benign groups was performed, a significantly shorter length of stay in both the malignant laparoscopic group (6.4 ± 6.4 vs 7.8 ± 6.6 days) and in the benign laparoscopic groups (5.1 ± 3.5 vs 7.2 ± 7.6) exists. A lower wound complication rate (2.1 vs 5.5%, malignant and 4.0 vs 6.1, benign) is also evident. Laparoscopic sigmoid colectomy was associated with a shorter length of stay, less complications, and a lower 30-day readmission rate. The shorter length of stay and wound infection rate maintain significance when comparing laparoscopic vs open sigmoid resections for malignant and benign disease.

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Authors and Affiliations

  1. Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA

    Marcelo W. Hinojosa, Zuri A. Murrell, Viken R. Konyalian, Steven Mills & Ninh T. Nguyen

  2. Department of Surgery, 333 City Blvd, West, Suite 850, Orange, CA, 92868, USA

    Michael J. Stamos

Authors
  1. Marcelo W. Hinojosa
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  2. Zuri A. Murrell
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  3. Viken R. Konyalian
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  4. Steven Mills
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  5. Ninh T. Nguyen
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  6. Michael J. Stamos
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Correspondence to Michael J. Stamos.

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Discussion

David Shibata, M.D. (Tampa, FL): Congratulations, too, on this paper. Thank you very much for submitting the manuscript to me in advance. That was much appreciated.

This is a very interesting paper in that this is kind of data that supports what has been borne out by multiple prospective randomized trials done in North America as well as in Europe, and it is kind of comforting to know that the data is very similar to what we see in those trials. Some of the things that come across is that this is more of a view from 30,000 feet as this study makes use of what appears to be a mini-SEER type database for academic centers.

The limitations are quite clear, as you have pointed out. It certainly does not allow you to focus on tumor-specific factors, on previous operations, the specific nature of the patient’s illnesses, and once again, it is really very difficult to tease out what is going on with the conversion rates.

First question. In terms of the codes for the procedures, I agree that there is no ICD-9 coding data, but it appears as if you have some financial data from this database. Can you actually look at the CPT codes that are associated with these billings and procedures?

Number two, in terms of the morbidity, I was a little surprised to see that in the sicker patients, even though this was just statistically non-significant, there was higher morbidity in some cases with laparoscopy than with open. This was one of your findings that I found to be a little discordant with some of the current data in the literature. And I was also wondering, did you actually stratify out parameters like pulmonary and cardiac complications when you analyzed the severity of the patients’ illnesses and comorbidities?

Finally, one of the interesting things that I found, when looking at the manuscript, was that of all sigmoid colon cancers in your dataset, only 5% of these cases were actually done laparoscopically; and these were at academic centers. Was this surprising to you? And furthermore, when you were looking at some of these institutions where these procedures were done, were the volumes heavily weighted in terms of a small number of institutions or were they evenly spread across many academic centers. From your data, it appears as if one-third of the academic centers did not do any laparoscopic colon surgery whatsoever.

And finally, I think this database also includes community centers, is that correct?

Marcelo W. Hinojosa, M.D. (Orange, CA): Yes, but only those that are affiliated with academic centers are included in the database.

Dr. Shibata: As we know from the history of laparoscopic cholecystectomy, oftentimes community surgeons led the way in popularizing some of these procedures. I would be curious to see, if you separated out the community centers whether the same percentages would hold out.

Thank you very much.

Dr. Hinojosa: Thank you, Dr. Shibata for your discussion and questions. In response to your first question regarding CPT codes. The UHC database does not list CPT codes. They use ICD-9 procedure and diagnostic codes exclusively. Therefore, there would be no way for us to find the CPT codes that were associated with the billings and procedures within the database.

In response to your second question regarding the higher morbidity seen in patients with the higher severity score that underwent laparoscopic resection, we were able to stratify by individual complications. However we believe that complications can be a somewhat subjective end point and may be a limitation within the database. Also, the groups of patients with higher severity of illness who underwent laparoscopic resection were a very small group compared to patients who underwent open resections. Patient selection can also have something to do with our findings.

In response to your third question as to whether we were surprised to find that about 5% of all cancer cases were done laparoscopically? The answer is not completely. As you know, the majority of laparoscopic colon resections performed for colon cancer up until a few years ago were performed only in randomized clinical trials. Therefore, we expected the numbers of laparoscopic resection for colon cancer to be lower than that of benign disease.

In response to your final question regarding procedure volume within each institution, we did not perform a volume analysis comparison between institutions. We will attempt to do the volume analysis comparison in a future study.

Steve Sentovich, M.D. (Boston, MA): I have a question related to surgeon volume. I would argue that you cannot make the conclusions that you do without stratifying for surgeon experience. If only very experienced surgeons are doing the laparoscopic cases then that could explain all of the differences that you found in terms of length of stay and morbidity. Did you look at specific surgeon volume and experience?

Dr. Hinojosa: Unfortunately, we are not able to stratify by specific surgeon or by surgeon experience using the UHC database.

Jonathan F. Critchlow, M.D. (Boston, MA): I think the sequel to that question is the selection bias. Are you cherry-picking? Are only the most experienced surgeons doing the cases, and of the ones they are doing, are they cherry-picking the ones that are going to be easy to do laparoscopically and then leaving the hard ones to be done open? You can’t tease out those specifics of each case. So it is interesting stuff, but I think we can say it is safe in selected circumstances.

Dr. Hinojosa: You are correct. Selection bias is a limitation of the study. From this database we can not tease out the specifics of each case and the experience of each surgeon. It is perceivable and even likely that the more experienced surgeons are performing laparoscopic cases. We do not know whether surgeons are “cherry picking”. However, we did stratify patient by severity of illness, which factors in patient comorbidities and secondary diagnoses.

The information contained in this article was based on the Clinical Data Base provided by the University HealthSystem Consortium.

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Hinojosa, M.W., Murrell, Z.A., Konyalian, V.R. et al. Comparison of Laparoscopic vs Open Sigmoid Colectomy for Benign and Malignant Disease at Academic Medical Centers. J Gastrointest Surg 11, 1423–1430 (2007). https://doi.org/10.1007/s11605-007-0269-x

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