Trends and consequences of surgical conversion in the United States

Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared with PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD.

METHODS

Using the National Readmission Database (NRD) 2016 to 2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by 3 weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. The primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis.

RESULTS

A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs. 13.71% P<0.0001), 90 days (14.63% vs. 13.14%, P<0.0001) but lower rate at 6 months (8.50% vs. 9.67%, P=0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 d vs. 6.74 d, P<0.0001), hospitalization cost ($106,947.97 vs. $97,602.25, P<0.0001), and overall mortality (6.86% vs. 4.35%, P<0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs. 6.88%, P=0.5382), 90 day (6.82% vs. 6.51%, P=0.5612), and 6 months (5.08% vs. 5.91%, P=0.1744).

CONCLUSIONS

ERCP demonstrated superior results compared with PTBD for readmission rates, length of stay and overall mortality. For failed ERCP cases, emerging data for Endoscopic ultrasound guided-biliary drainage (EUS-BD) offers potential over PTBD and may provide additional options for the future in tertiary referral centers with experience.

On-demand robotics-The best of both worlds for robotic-assisted laparoscopic surgery

A modular, combined use of robotic and laparoscopic platforms has been suggested to address challenges in optimal workspace utilization. The 3-arm on-demand open Dexter Robotic System was developed to combine the advantages of robot-assisted precision surgery in narrow spaces with the laparoscopic approach for frequent position changes in larger spaces. The system integrates 2 patient carts, a fully controllable endoscope arm, and a sterile surgeon open console, allowing for a rapid switch between robot-assisted surgery and laparoscopy. When switching, the robotic arms may be folded into a laparoscopic home position at any time during a procedure, allowing unrestricted access to the patient. Switches take 15-30 seconds, occurring seamlessly without redocking or recalibrating upon returning to the robotic mode. During oncologic colorectal resections, some procedure steps (eg, central vessel ligation and lymphadenectomy) are best suited for the robotic approach, providing advantages related to 3-dimensional vision, improved ergonomics, and improved dexterity within confined spaces. In contrast, the laparoscopic platform is better suited for procedure steps requiring frequent movements within a large workspace (eg, lateral to medial mobilization of the colon). The Dexter system provides a portfolio of 7 robotic instruments with monopolar and bipolar function operating with any existing available generator. Furthermore, existing operating room equipment, including insufflating devices, optics, and trocars can be used with the Dexter robotic platform. Recently, the first published clinical experience from the authors' institution, involving 12 pilot cases, demonstrated the safety and feasibility for right colonic resections for benign and malignant indications and ventral mesh rectopexies.

Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer

AIM

Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT.

METHODS

An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak.

RESULTS

A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort.

CONCLUSION

In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion

OBJECTIVE

With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy.

METHODS

This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability.

RESULTS

Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of   III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001).

CONCLUSIONS

Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease

BACKGROUND

Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD.

METHODS

Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed.

RESULTS

The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results.

CONCLUSION

The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Perioperative outcomes of robotic and laparoscopic surgery for colorectal cancer: a propensity score-matched analysis

BACKGROUND

Robotic colorectal surgery is becoming the preferred surgical approach for colorectal cancer (CRC). It offers several technical advantages over conventional laparoscopy that could improve patient outcomes. In this retrospective cohort study, we compared robotic and laparoscopic surgery for CRC using a national cohort of patients.

METHODS

Using the colectomy-targeted ACS-NSQIP database (2015-2020), colorectal procedures for malignant etiologies were identified by CPT codes for right colectomy (RC), left colectomy (LC), and low anterior resection (LAR). Optimal pair matching was performed. "Textbook outcome" was defined as the absence of 30-day complications, readmission, or mortality and a length of stay < 5 days.

RESULTS

We included 53,209 out of 139,759 patients screened for eligibility. Laparoscopic-to-robotic matching of 2:1 was performed for RC and LC, and 1:1 for LAR. The largest standardized mean difference was 0.048 after matching. Robotic surgery was associated with an increased rate of textbook outcomes compared to laparoscopy in RC and LC, but not in LAR (71% vs. 64% in RC, 75% vs. 68% in LC; p < 0.001). Robotic LAR was associated with increased major morbidity (7.1% vs. 5.8%; p = 0.012). For all three procedures, the mean conversion rate of robotic surgery was lower than laparoscopy (4.3% vs. 9.2%; p < 0.001), while the mean operative time was higher for robotic (225 min vs. 177 min; p < 0.001).

CONCLUSIONS

Robotic surgery for CRC offers an advantage over conventional laparoscopy by improving textbook outcomes in RC and LC. This advantage was not found in robotic LAR, which also showed an increased risk of serious complications. The associations highlighted in our study should be considered in the discussion of the surgical management of patients with colorectal cancer.

Robotic Redo Ileocolonic Resection for Crohn's Disease: A Preliminary Report From a Tertiary Care Center

BACKGROUND

Although the safety of laparoscopic redo ileocolonic resection for Crohn's disease has been described before, the safety of robotic redo ileocolonic resection is still unelucidated.

OBJECTIVE

This study aimed to share our preliminary experience regarding the safety of robotic redo ileocolonic resection for Crohn's disease.

DESIGN

Retrospective analysis.

SETTING

Tertiary care center.

PATIENTS

All consecutive adult patients who underwent robotic ileocolonic resection for Crohn's disease at our institution between 2014 and 2021 were included. Patients were divided into redo ileocolonic resection and primary ileocolonic resection groups.

PRIMARY OUTCOME MEASURES

Baseline demographics, preoperative risk factors, and intraoperative details were compared between both groups. The primary outcome was conversion to an open approach, and secondary outcomes were 30-day postoperative complications.

RESULTS

A total of 98 patients were included. Of them, 18 (18.4%) had a redo ileocolonic resection. Patients who had a redo ileocolonic resection were more likely to have a longer duration of disease, associated anoperineal disease, a higher number of previous lines of medical treatments, received total parental nutrition before the operation for correction of malnutrition, and longer time for adhesiolysis. Patients who had redo ileocolonic resection had a higher risk for conversion to open ileocolonic resection [3 (16.7%) versus 2 (2.5%); p value = 0.04]. There was no statistically significant difference regarding the overall length of stay and the 30-day morbidity between both groups. No 30-day mortality or anastomotic leaks occurred in either group.

LIMITATIONS

Retrospective nature of the analysis.

CONCLUSIONS

Robotic redo ileocolonic resection showed similar short-term postoperative outcomes to robotic primary ileocolonic resection for Crohn's disease. However, conversion rates are higher in robotic redo ileocolonic resection yet seem lower than previously published results in laparoscopic surgery. See Video Abstract at http://links.lww.com/DCR/C77 .

RESECCIN ILEOCLICA ROBTICA REDO PARA LA ENFERMEDAD DE CROHN INFORME PRELIMINAR DE UN CENTRO DE ATENCIN TERCIARIA

ANTECEDENTES:Si bien la seguridad de la resección ileocolónica laparoscópica para la enfermedad de Crohn se ha descrito antes, la seguridad de la resección ileocolónica robótica aún no se ha dilucidado.OBJETIVO:Este estudio tuvo como objetivo compartir nuestra experiencia preliminar con respecto a la seguridad de la resección ileocolónica robótica para la enfermedad de Crohn.DISEÑO:Análisis retrospectivo.AJUSTE:Centro de atención terciaria.PACIENTES:Se incluyeron todos los pacientes adultos consecutivos que se sometieron a resección ileocolónica robótica por enfermedad de Crohn en nuestra institución entre 2014 y 2021. Los pacientes se dividieron en grupos de resección ileocolónica reconfeccionada y resección ileocolónica primaria.MEDIDAS DE RESULTADO:Se compararon los datos demográficos iniciales, los factores de riesgo preoperatorios y los detalles intraoperatorios entre ambos grupos. El resultado primario fue la conversión a abierto y los resultados secundarios fueron las complicaciones posoperatorias a los treinta días.RESULTADOS:Se incluyeron un total de 98 pacientes. De ellos, 18 (18,4%) tuvieron resección ileocolónica. Los pacientes que se sometieron a una nueva resección ileocolónica tenían más probabilidades de tener una mayor duración de la enfermedad, enfermedad anoperineal asociada, un mayor número de líneas previas de tratamientos médicos, más probabilidades de haber recibido nutrición parental total antes de la operación para la corrección de la desnutrición y más tiempo tiempo de adhesiolisis. Los pacientes que se sometieron a una nueva resección ileocolónica tuvieron un mayor riesgo de conversión a cirugía abierta [3 (16,7 %) frente a 2 (2,5 %); valor p 0,04]. No hubo diferencia estadísticamente significativa con respecto a la duración total de la estancia y la morbilidad a los treinta días entre ambos grupos. No hubo mortalidad a los treinta días ni fugas anastomóticas en ninguno de los grupos.LIMITACIONES:Naturaleza retrospectiva del análisis.CONCLUSIÓN:La resección ileocolónica robótica mostró resultados postoperatorios a corto plazo similares a la resección ileocolónica primaria robótica para la enfermedad de Crohn. Sin embargo, las tasas de conversión son más altas en la resección ileocolónica robótica, pero parecen más bajas que los resultados publicados previamente en la cirugía laparoscópica. Consulte Video Resumen en http://links.lww.com/DCR/C77 . (Traducción-Dr Yolanda Colorado ).

Postoperative Safety Profile of Minimally Invasive Ileocolonic Resections for Crohn's Disease in the Era of Biologic Therapy

BACKGROUND

There is controversy regarding the postoperative outcomes in Crohn's disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy.

METHODS

All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon's discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications.

RESULTS

A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease.

CONCLUSIONS

This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn's disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn's disease. Further studies with larger sample sizes are needed to confirm results.

Perioperative outcomes of minimally invasive ileocolic resection for complicated Crohn disease: Results from a referral center retrospective cohort

BACKGROUND

Minimally invasive ileocolic resection for complicated Crohn disease, defined as penetrating Crohn disease associated with intra-abdominal fistula, abscess, or phlegmon, is challenging. In addition, the impact of the minimally invasive approach on postoperative outcomes is still debated. This study aimed to compare the intraoperative and postoperative outcomes of minimally invasive ileocolic resection for complicated versus uncomplicated Crohn disease.

METHODS

A retrospective analysis of all consecutive adult patients with Crohn disease undergoing minimally invasive ileocolic resection from 2014 to 2021 was performed. Perioperative outcomes were compared between patients with complicated Crohn disease (complicated group) and patients without these lesions (uncomplicated group).

RESULTS

Among the 274 patients undergoing minimally invasive ileocolic resection for Crohn disease, 101 (36.9%) had a robotic approach, and 84 (30.7%) had complicated Crohn disease. Complicated patients were more frequently malnourished (32.1% vs 16.1%, P = .004) and had more frequent previous bowel resections for Crohn disease (22.1% vs 9.5%, P = .002). There were no differences between both groups regarding intraoperative complications (1.1% uncomplicated group vs 2.4% complicated group, P = .463), conversion rate (2.6% uncomplicated group vs 4.8% complicated group, P = .463), postoperative morbidity (27.4% uncomplicated group vs 34.5% complicated group, P = .231), intra-abdominal septic complications (4.2% uncomplicated group vs 7.1% complicated group, P = .309), and length of stay (3.8 ± 2.0 days uncomplicated group vs 4.2 ± 3.0 complicated group, P = .188).

CONCLUSION

Minimally invasive ileocolic resection for complicated Crohn disease is safe and feasible. Future prospective studies are needed to confirm these results.

Minimally invasive ileal pouch-anal anastomosis for patients with obesity: a propensity score-matched analysis

BACKGROUND

Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity.

MATERIALS AND METHODS

All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m² vs. BMI < 30 kg/m²). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups.

RESULTS

Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay.

CONCLUSION

MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections.