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Ng AP, Cho NY, Kim S, Ali K, Mallick S, Lee H, Benharash P. National analysis of racial disparities in emergent surgery for colorectal cancer. Surg Open Sci 2024; 18:35-41. [PMID: 38318320 PMCID: PMC10838942 DOI: 10.1016/j.sopen.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
Background Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery. Methods All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends. Results Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type. Conclusion Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.
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Affiliation(s)
- Ayesha P. Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shineui Kim
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Hanjoo Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Calini G, Abdalla S, Abd El Aziz MA, Merchea A, Larson DW, Behm KT. Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis. J Robot Surg 2023; 17:2157-2166. [PMID: 37264221 DOI: 10.1007/s11701-023-01635-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amit Merchea
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease. Langenbecks Arch Surg 2023; 408:251. [PMID: 37382678 DOI: 10.1007/s00423-023-02976-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/10/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Calini G, Abdalla S, Abd El Aziz MA, Benammi S, Merchea A, Behm KT, Mathis KL, Larson DW. Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center. Updates Surg 2023:10.1007/s13304-023-01528-1. [PMID: 37149508 DOI: 10.1007/s13304-023-01528-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/29/2023] [Indexed: 05/08/2023]
Abstract
Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sarah Benammi
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Calini G, Abdalla S, Aziz MAAE, Behm KT, Shawki SF, Mathis KL, Larson DW. Incisional Hernia rates between Intracorporeal and Extracorporeal Anastomosis in Minimally Invasive Ileocolic Resection for Crohn's disease.. [DOI: 10.21203/rs.3.rs-2591968/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Abstract
Purpose: One-third of patients with Crohn’s disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M).
Methods: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center.
Results: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p=0.064] and readmission rates [7(11.9) vs. 18(9.5); p=0.59].
Conclusion: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Calini G, Abdalla S, Abd El Aziz MA, Saeed HA, D'Angelo ALD, Behm KT, Shawki S, Mathis KL, Larson DW. Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease. J Robot Surg 2021; 16:601-609. [PMID: 34313950 DOI: 10.1007/s11701-021-01283-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Hamedelneel A Saeed
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Anne-Lise D D'Angelo
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Enhanced Recovery: A Decade of Experience and Future Prospects at the Mayo Clinic. HEALTHCARE (BASEL, SWITZERLAND) 2021; 9:healthcare9050549. [PMID: 34066696 PMCID: PMC8150975 DOI: 10.3390/healthcare9050549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023]
Abstract
This work aims to describe the implementation and subsequent learnings from the first decade after the full implementation of enhanced recovery pathway for colorectal surgery at a single institution. This paper will describe the diffusion efforts and plans through the Define, Measure, Analyze, Improve, Control (DMAIC) process of ongoing quality improvement and through research efforts. The information applies to all readers that provide surgical care within their organization as the fundamental principles of enhanced recovery for surgery are applicable regardless of the setting.
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Jeong O, Jang A, Jung MR, Kang JH, Ryu SY. The benefits of enhanced recovery after surgery for gastric cancer: A large before-and-after propensity score matching study. Clin Nutr 2021; 40:2162-2168. [DOI: 10.1016/j.clnu.2020.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/24/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
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Abstract
BACKGROUND Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. OBJECTIVE This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. PATIENTS Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. MAIN OUTCOME MEASURES Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. RESULTS In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. LIMITATIONS Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. CONCLUSIONS Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.
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Ramirez-Caban L, Kannan A, Goggins ER, Shockley ME, Haddad LB, Chahine EB. Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy. JSLS 2020; 24:JSLS.2020.00029. [PMID: 32714003 PMCID: PMC7362931 DOI: 10.4293/jsls.2020.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol. Methods A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015. Results Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization. Conclusion Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.
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Using Electronic Medical Records to Identify Enhanced Recovery After Surgery Cases. EGEMS 2019; 7:34. [PMID: 31380461 PMCID: PMC6662533 DOI: 10.5334/egems.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Context: Enhanced recovery after surgery (ERAS) aims to improve surgical outcomes by integrating evidence-based practices across preoperative, intraoperative, and postoperative care. Data in electronic medical records (EMRs) provide insight on how ERAS is implemented and its impact on surgical outcomes. Because ERAS is a multimodal pathway provided by multiple physicians and health care providers over time, identifying ERAS cases in EMRs is not a trivial task. To better understand how EMRs can be used to study ERAS, we describe our experience with using current methodologies and the development and rationale of a new method for retrospectively identifying ERAS cases in EMRs. Case Description: Using EMR data from surgical departments at the University of North Carolina at Chapel Hill, we first identified ERAS cases using a protocol-based method, using basic information including the date of ERAS implementation, surgical procedure and date, and primary surgeon. We further examined two operational flags in the EMRs, a nursing order and a case request for OR order. Wide variation between the methods compelled us to consult with ERAS surgical staff and explore the EMRs to develop a more refined method for identifying ERAS cases. Method: We developed a two-step method, with the first step based on the protocol definition and the second step based on an ERAS-specific medication definition. To test our method, we randomly sampled 150 general, gynecological, and urologic surgeries performed between January 1, 2016 and March 30, 2017. Surgical cases were classified as ERAS or not using the protocol definition, nursing order, case request for OR order, and our two-step method. To assess the accuracy of each method, two independent reviewers assessed the charts to determine whether cases were ERAS. Findings: Of the 150 charts reviewed, 74 were ERAS cases. The protocol only method and nursing order flag performed similarly, correctly identifying 74 percent and 73 percent of true ERAS cases, respectively. The case request for OR order flag performed less well, correctly identifying only 44 percent of the true ERAS cases. Our two-step method performed well, correctly identifying 98 percent of true ERAS cases. Conclusion: ERAS pathways are complex, making study of them from EMRs difficult. Current strategies for doing so are relatively easy to implement, but unreliable. We have developed a reproducible and observable ERAS computational phenotype that identifies ERAS cases reliably. This is a step forward in using the richness of EMR data to study ERAS implementation, efficacy, and how they can contribute to surgical care improvement.
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Abstract
PURPOSE OF REVIEW Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an open approach. Reasons for this may include technical difficulties associated with operating in narrow spaces such as in the pelvis and inadequate experience. Robotic surgery provides potential solutions to some of these challenges. This review will summarize the state of the literature regarding robotic colorectal surgery. RECENT FINDINGS The most consistent benefit of robotic surgery is decreasing operative conversions, specifically in rectal cancer. In partial colectomies, there is evidence to support quicker return to bowel function. Oncologic outcomes compared to the laparoscopic approach are equivalent. Robotic surgery provides solutions to the challenges posed by laparoscopy, including wristed instruments, ease of intracorporeal suturing, and ergonomic advantages. Randomized trials to evaluate peri-operative outcomes will be important. If robotics is able to facilitate conversion of open colectomies to their minimally invasive equivalent, robotics may end up proving to be advantageous in the peri-operative and post-operative period. Continued studies are warranted.
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Affiliation(s)
- Harith H Mushtaq
- General Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.331, Houston, TX, 77030, USA
| | - Shinil K Shah
- Minimally Invasive and Elective General Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Amit K Agarwal
- Colon and Rectal Surgery, McGovern Medical School at UT Health, 6431 Fannin Street, MSB 4.158, Houston, TX, 77030, USA.
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