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01. Patient Comparative Staging Colorectal ppt Sunumu İndir

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[1]
A Comparative Study Among Elective Conventional Surgery, Urgency/Emergency Conventional Approaching and Elective Videolaparoscopic Surgery on the Treatment of Hospitalized Patients at First Surgeric Clinic of Federal Hospital of Bonsucesso with a Diagnostic of Colorectal Adenocarcinoma, between January 2010 and December 2012.Coauthors: Flavio Antonio de Sá Ribeiro; Flavia Secco Tavares de Souza; Bárbara de Oliveira Urquiaga; Mariana Artimos Da Matta Tenório; Baltazar De Araújo Fernandes
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• Patients with colorectal adenocarcinoma who underwent surgery in the years 2010, 2011 and 2012 in the 1st Surgical Clinic of the Federal Hospital Bonsucesso•Surgeries:1. Conventional Approach to Emergency 2. Conventional Elective Surgery3. Elective Laparoscopic SurgeryStudy Population
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•Pre-selection of histopathological reports in Anatomic Pathology Service (March-July / 2013)•Selection with data collection in Medical Records (August / 2013 - May / 2014) grouped according to the surgery performedData Collection
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Selected dataSexAge• up to 39 years• 40 to 65 years• over 65 yearsTNM stageLength of Stay• Up to 15 days• 15 to 30 days• 30 to 40 days• more than 40 daysComplicationsData Collection
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Clavien Classificationwww.indianjurol.com
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• Selected sample: 227 patients10,57%65,63%23,78%020406080100120140160Emergency Elective Laparotomy Elective LaparoscopySampleOutcomes
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8,33%66,66%25%05101520up to 39 years 40 to 65 years over 65 yearsAgeAVERAGE AGE 55,666MEDIAN AGE 57,000STANDARD DEVIATION OF AGE 15,465Outcomes - Emergency
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83,33%8,33%0,00%8,33%024681012141618202215 days 15 to 30 days 30 to 40 days more than 40 daysLength of StayOutcomes - Emergency
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54,16%4,16% 8,33%0%4,16%0%8,33%20,83%02468101214ComplicationsOutcomes - Emergency
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8,33%12,5%8,33%25%20,83%25%01234567Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV Not foundStagingOutcomes - Emergency
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3,35%45,63%51%01020304050607080up to 39 years 40 to 65 years over 65 yearsAgeAVERAGE AGE 64,348MEDIAN AGE 66,000STANDARD DEVIATION OF AGE 12,684Outcomes – Conventional Elective Surgery
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27,51%41,61%13,42%17,44%01020304050607015 days 15 to 30 days 30 to 40 days more than 40 daysLength of StayOutcomes – Conventional Elective Surgery
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26,17%16,10%13,42%4,02%8,72%5,36%5,36%20,88%051015202530354045ComplicationsOutcomes – Conventional Elective Surgery
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10,06%8,72%14,76%2,01% 3,35%16,77%12,08%32,21%0102030405060Stage I Stage IIA  Stage IIB  Stage IIIA Stage IIIB  Stage IIIC Stage IV  Not FoundStagingOutcomes – Conventional Elective Surgery
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3,70%55,55%40,74%05101520253035up to 39 years 40 to 65 years over 65 yearsAgeAVERAGE AGE 61,833MEDIAN AGE 63,000STANDARD DEVIATION OF AGE 12,319Outcomes – Elective Laparoscopic Surgery
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33,33%51,85%9,25% 5,55%05101520253015 days 15 to 30 days 30 to 40 days more than 40 daysLength of StayOutcomes – Elective Laparoscopic Surgery
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53,70%14,81%18,51%0% 0%3,70%0%9,25%05101520253035ComplicationsOutcomes – Elective Laparoscopic Surgery
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25,92%11,11%9,25%1,85%7,40%11,11% 11,11%22,22%0246810121416Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV Not FoundStagingOutcomes – Elective Laparoscopic Surgery
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The groups were compared by evaluating the comparative significance of the variables Statistical evaluation highlighted three variables•  Length of stay (p-value = 0,000004970)•  Complications (p-value = 0,04734)•  Staging (p-value = 0,002072)Biostatistical Analysis
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It is not only important to embrace the advantages but also to understand its limitations and complicationsMinimally Invasive Approaches X Open Surgery
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• Insertion - Minimal violation of the anterior peritoneum - Patient-specific factors decides which method to use- Dreaded complication: missed intestinal injury- Dense adhesions suspected: choose an entry site away from the prior incisionComplications Related to Trocars
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• Bleeding Port Sites- Piercing or laceration of vessels traversing the abdominal wall during trocar placement is generally the cause - The most common vascular injury: inferior epigastric vessels- Methods to control bleeding: suture placement around the trocar site, standard electrocautery or port removal with direct suture ligationComplications Related to Trocars
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• Adhesions and Port-site Hernias – Intra-abdominal adhesions in laparoscopic intestinal surgery are reducedComplications Related to TrocarsTaylor GW and colleagues: “Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASSIC trial.” [Br J Surg 2010]There was an increase in rates of both adhesions and hernia complications among patients whose procedure was converted from a laparoscopic approach to open
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• Port-site Tumor Recurrence XComplications Related to TrocarsReported rates of port-site tumor recurrences early in the experience of laparoscopic surgery for colon cancer were as high as 21%It appears that the previously unexpected high rates of port tumor recurrences are not observed in the latest updates of all large randomized controlled trials
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• Leak Rates Relative to Technique of Anastomosis- Anatomic location within the bowel- Anatomy- Mesenteric mobility- Bacterial load differ by location along the lower gastrointestinal tract- Tension- Blood supplyIntra-abdominal Complications
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SIGNIFICANT BENEFITS FROM LAPAROSCOPY1. Earlier return of bowel function2. Decreased postoperative pain3. Shorter length of stay4. Lower late morbidity rates 5. Reduced ileus6. Lower estimated blood loss7. Lower transfusion rate8. Lower wound infections Intra-abdominal Complications
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• Injury to the Genitourinary Tract → the incidence of urinary tract injuries increases in patients with:- Prior pelvic operations- Inflammatory bowel disease- Infection- Patients with extensive neoplasms that can cause distortion of normal surgical planesIntra-abdominal Complications
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• Conversion from laparoscopic to open surgery is affected by variety of patient-related, as well as surgeon-related factors• Patient-related factors:1.Dense interloop adhesions2.High body mass index3.Advanced tumor with local invasion4.Inflammatory conditionsConversion
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Patients who were converted during laparoscopic colectomies when compared with those who had successful laparoscopic colectomies had longer operative time, increased blood loss, higher wound infecion rate and longer lenght of stayMarusch F and colleagues: “Importance of conversion for results obtained with laparoscopic colorectal surgery.” [Dis Colon Rectum 2006]Conversion
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Favorable outcome in high-risk patientsIntraoperative complications and poorer outcomesConversionClinical impact of conversion also depends on whether the case is converted early (< 30 minutes) or lateEarly Proactive Conversion X Reactive Conversionl i i
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Most patients undergoing emergency surgery had a shorter length of stay (p-value = 0,00000497)0%20%40%60%80%100%15 days 15 to 30 days 30 to 40 days more than 40daysEmergencyElective LaparatomyElective LaparoscopyConclusions
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• The group operated by laparoscopy had lower incidence of complications when compared to elective laparotomy group (p-value = 0,002072) • Conventional elective surgeries: the percentage of deaths was high0%10%20%30%40%50%60%EmergencyElective LaparatomyElective LaparoscopyConclusions
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Conclusions• Many patients undergoing laparoscopic surgery were in the earliest stages of the disease. And, conversely, a high percentage of patients undergoing emergency surgery was in the advanced stages of the disease (p-value = 0,047)0%5%10%15%20%25%30%35%Stage I StageIIAStageIIBStageIIIAStageIIIBStageIIICStageIVNotfoundEmergencyElective LaparatomyElective Laparoscopy
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1. Laparoscopic colorectal surgery may be comparable to open techniques when considering oncological and long-term follow-up outcomesKey-Points2. Although fewer perioperative complications and faster postoperative recovery of laparoscopy, it does possess a unique set of complications3. Complications resulting from conversion of procedures from laparoscopic-to-open may lead to worse outcomes than complications from open surgery alone
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