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Study was an open and shut case

By Amos Esty

Medical residents have a lot to learn. So when Jason Kemp, M.D., a fourth-year general-surgery resident, started thinking about the time it would take to master a minimally invasive approach to colon surgery, he had some concerns. "Is it something that I wanted to spend a lot of time learning?" he asked himself. "Does it translate into better outcomes for the patient?"

Colon: More than 100,000 elective colectomies-surgeries to remove all or part of the colon-are performed each year in the U.S. to treat inflammatory bowel disease, cancer, and a number of other conditions. Most are done with the traditional open procedure, in which a surgeon makes a long incision down the middle of the patient's abdomen. The number of colectomies performed with a laparoscopic-or minimally invasive-approach is growing, but it's not an easy procedure to learn. A surgeon makes several tiny incisions in the abdomen and inserts a video camera through one and tiny instruments through the others. The camera transmits a view of the operative field to monitors in the operating room, and the surgeon watches the monitors while removing the diseased portion of the colon.

Clinical trials have shown that the laparoscopic approach has a number of advantages, including shorter hospital stays, lower complication rates, and less pain. But Kemp and Samuel Finlayson, M.D., M.P.H., an associate professor of surgery, felt that those trials-although important-had some limitations. "Clinical trials are necessarily limited to relatively small numbers of patients in a limited number of institutions," Finlayson says. And, Kemp adds, some of the trials had stringent selection criteria, meaning the conclusions were based on surgeries done by experienced doctors at large academic medical centers.

Kemp and Finlayson wanted to know if the findings from trials applied everywhere-including in small hospitals, where surgeons might not perform as many laparoscopic procedures. They examined outcomes from thousands of laparoscopic and open colon resections, conducted from 2000 to 2004, using data in the Nationwide Inpatient Sample, a database filled with information on more than 8 million hospital stays each year at a variety of hospitals.

Laparoscopy: Their conclusions, published in Surgical Innovation, add to the evidence for the advantages of laparoscopy. The complication rate was 32.1% for patients who had a laparoscopic colectomy, and 38.2% for the open operation. The minimally invasive procedure also resulted in shorter hospital stays and lower mortality.

Between 2000 and 2004, only 4.4% of the elective colon resections performed nationwide were done laparoscopically. But Kemp and Finlayson say the approach has gained popularity in recent years and is likely to continue to do so. As for Kemp, he's now convinced that learning the procedure will be time well spent.

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