Why Aren’t More Surgeons Using Minimally Invasive Techniques for Emergent Colorectal Surgery?

By Thomas Crocker
Monday, September 26, 2022

A recent study concluded that minimally invasive techniques are associated with better outcomes for patients who undergo emergent colorectal surgery. The study also identified factors that may account for the disparity in the use of these techniques for emergent operations compared with elective surgeries.

Minimally invasive techniques, such as laparoscopy and robotic surgery, have transformed colorectal surgery in recent decades. Using data from the Washington state-based Surgical Care and Outcomes Assessment Program (SCOAP), a 2020 study in the Journal of Gastrointestinal Surgery found that, across 21,423 elective colorectal surgeries, minimally invasive surgery rates increased from 44% in 2011 to 75% by 2018.

The use of minimally invasive techniques is far less common for emergent colorectal surgery. A 2019 study in the Journal of Surgical Research featuring 16,277 patients from the Florida Inpatient Discharge Dataset found that, among individuals who underwent emergent colorectal surgery, 31.8% received minimally invasive operations. Among elective surgery patients, 48.1% were minimally invasive cases.

Vlad Simianu, MD, MPH, FACS, FASCRS, Medical Director of Colon and Rectal Disorders for the Center of Digestive Health at Virginia Mason Medical Center in Seattle, and one of the authors of the 2020 study, set out with colleagues to investigate the disparity between minimally invasive emergent and elective colorectal surgeries.

“About 1 in 4 colon resections happen emergently,” Dr. Simianu says. “In those patients, minimally invasive surgery is used [much] less often, and we’re trying to figure out if we could get insights into why that is. The technology is there, surgeons know how to use these approaches and we know they’re beneficial for patients. So why isn’t this happening as often in emergency cases, and particularly in older adults, because we think the benefits of minimally invasive surgery would be particularly high in those folks?”

Minimally Invasive Surgery Yields ‘Big’ Benefits for Emergent Patients

Dr. Simianu and his colleagues designed a retrospective cohort study using data from 50 SCOAP-participating hospitals. They analyzed 6,913 emergent colorectal surgery cases performed at SCOAP hospitals from 2011 to 2019. The team defined minimally invasive cases based on the surgeons’ intention to treat, meaning that surgeries that began using minimally invasive approaches were classified as minimally invasive. Surgeons were found to have used minimally invasive approaches in 23.4% of cases.

The researchers stratified the cases into three age groups — patients younger than age 65, patients 65 to 74, and patients 75 and older. Overall, compared with patients who underwent open operations, patients who underwent minimally invasive surgery had a higher discharge-to-home rate (77.8% vs. 62.8%), a lower rate of adverse events (33.1% vs. 49.1%) and a shorter length of stay (a median of six days vs. eight days). Minimally invasive surgery continued to reduce adverse events across all age groups after adjustment for demographic factors, BMI and primary surgical site. The findings appeared in The American Journal of Surgery in 2022.

Dr. Simianu says the results are remarkable because patients who need emergent surgery are typically sicker than elective surgery patients, which increases the likelihood of adverse events.

“What was striking was how big the benefits [of minimally invasive surgery] were,” he says. “Even if you do minimally invasive surgery in an emergency setting, it’s hard because you can’t control all of the things that happen with patients. Maybe they didn’t do bowel prep or stop a blood thinner, [which are] things you can do in an elective setting, so we would expect them to do worse. But even then, minimally invasive surgery had a pretty dramatic impact.”

Why, then, such a low rate of usage?

Questions of Timing, Training and Perceptions of Patient Tolerance

Dr. Simianu observed that studies like this one can raise new questions. For example, the authors assumed most emergency surgeries would take place at night. They wrote, “Potential barriers to [minimally invasive surgery] use may come in the form of access to equipment or experienced teams with [minimally invasive surgery] technology based on the time of day the procedure is performed. Disease acuity may mandate a middle of the night operation. Accordingly, the lowest use of minimally invasive surgery during this study was at night.”

However, 70% of emergent cases occurred from 6 a.m. to 6 p.m. when, theoretically, the personnel and equipment to perform minimally invasive surgery should have been available. During prime operating hours, less than 40% of patients underwent minimally invasive surgery, and the reasons are unclear.

Another potential barrier to minimally invasive surgery: On-call surgeons may have less experience at performing colorectal surgery and using minimally invasive techniques than surgeons who perform elective operations.

Minimally invasive surgery was more likely in patients younger than 65, perhaps, Dr. Simianu says, due to misperceptions about older patients’ ability to tolerate these procedures.

“[W]hen you account for how sick the patient was, what time of day it was, all of these factors, there are many cases that could be done safely using minimally invasive surgery,” he says. “I think it’s a big opportunity because these are patients who don’t bounce back from surgery quite as quickly as their younger counterparts, so minimally invasive surgery might have a significant benefit [for them].”