Comparison of laparoscopic vs open sigmoid colectomy for benign and malignant disease at academic medical centers

Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

Background and Objectives

Regional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes.

Methods

A retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models.

Results

Of 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use.

Discussion

Multiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.

Risk factors for surgical site infections following open versus laparoscopic colectomies: a cohort study

Background

Surgical site infections (SSIs) are among the most common healthcare-associated infections. Evaluating risk factors for SSIs among patients undergoing laparoscopic and open colorectal resections can aid in selecting appropriate candidates for each modality.

Methods

A cohort of all consecutive patients undergoing elective colorectal resections during 2008–2017 in a single center was analyzed. SSIs were prospectively assessed by infection control personnel. Patient data were collected from electronic medical records. Risk factors for SSIs were compared between patients who underwent laparoscopic and open surgeries. A multivariate analysis was performed for significant variables.

Results

During the study period, 865 patients underwent elective colorectal resection: 596 laparoscopic and 269 open surgeries. Mean age was 68.2 ± 15.1 years, weight 72.5 ± 18.3 kg and 441 (51%) were men. The most common indication for surgery was malignancy, in 767 patients (88.7%) with inflammatory bowel diseases and diverticulitis following (4.5% and 3.9%, respectively). Patients undergoing laparoscopic surgery were younger, had fewer comorbidities, shorter pre-operative hospitalizations, lower risk index scores, and lower rates of SSI, compared with open surgery. Independent risk factors for SSI following laparoscopic surgery were chronic obstructive pulmonary disease [odds ratio (OR) 2.655 95% CI (1.267, 5.565)], risk index ≥ 2 [OR 2.079, 95% CI (1.041,4.153)] and conversion of laparoscopic to open surgery [OR 2.056 95%CI (1.212, 3.486)]. Independent risk factors for SSI following open surgery were immunosuppression [OR 3.378 95% CI (1.071, 10.655)], chronic kidney disease [OR 2.643 95% CI (1.008, 6.933)], and need for a second dose of prophylactic antibiotics [OR 2.519 95%CI (1.074, 5.905)].

Conclusions

Risk factors for SSIs differ between laparoscopic and open colorectal resections. Knowledge of specific risk factors may inform patient selection for these modalities.

Diagnosis and Management of Intraoperative Colorectal Anastomotic Leaks: A Global Retrospective Patient Chart Review Study

Background

This targeted chart review study reports the first ever detailed global account of clinical approaches adopted to detect and manage anastomotic leaks identified during surgery in routine clinical practice.

Method

156 surgeons from eight countries retrospectively extracted data from surgical records of 458 patients who underwent colorectal surgery with an identified intraoperative leak at the circular anastomosis. Demographic details, procedures, and outcomes were analyzed descriptively, by country.

Results

Most surgeries were performed laparoscopically (57.6%), followed by open surgeries (35.8%). The burden of intraoperative leaks on the healthcare system is driven in large part by the additional interventions such as using a sealant, recreating the anastomosis, and diverting the anastomosis to a colostomy bag, undertaken to manage the leak. The mean duration of hospitalization was 19.9 days. Postoperative anastomotic leaks occurred in 62 patients (13.5%), most frequently 4 to 7 days after surgery. Overall, country-specific differences were observed in patient characteristics, surgical procedures, method of diagnosis of intraoperative leak, interventions, and length of hospital stay.

Conclusion

The potential cost of time and material needed to repair intraoperative leaks during surgery is substantial and often hidden to the healthcare system, potentially leading to an underestimation of the impact of this complication.

Human Albumin Use in Adults in U.S. Academic Medical Centers

OBJECTIVE

To determine rates and predictors of albumin administration, and estimated costs in hospitalized adults in the United States.

DESIGN

Cohort study of adult patients from the University HealthSystem Consortium database from 2009 to 2013.

SETTING

One hundred twenty academic medical centers and 299 affiliated hospitals.

PATIENTS

A total of 12,366,264 hospitalization records.

INTERVENTIONS

Analysis of rates and predictors of albumin administration, and estimated costs.

MEASUREMENTS AND MAIN RESULTS

Overall the proportion of admissions during which albumin was administered increased from 6.2% in 2009 to 7.5% in 2013; absolute difference 1.3% (95% CI, 1.30-1.40%; p < 0.0001). The increase was greater in surgical patients from 11.7% in 2009 to 15.1% in 2013; absolute difference 3.4% (95% CI, 3.26-3.46%; p < 0.0001). Albumin use varied geographically being lowest with no increase in hospitals in the North Eastern United States (4.9% in 2009 and 5.3% in 2013) and was more common in bigger (> 750 beds; 5.2% in 2009 and 7.3% in 2013) compared to smaller hospitals (< 250 beds; 4.4% in 2009 to 6.2% in 2013). Factors independently associated with albumin use were appropriate indication for albumin use (odds ratio, 65.220; 95% CI, 62.459-68.103); surgical admission (odds ratio, 7.942; 95% CI, 7.889-7.995); and high severity of illness (odds ratio, 8.933; 95% CI, 8.825-9.042). Total estimated albumin cost significantly increased from $325 million in 2009 to $468 million in 2013; (absolute increase of $233 million), p value less than 0.0001.

CONCLUSIONS

The proportion of hospitalized adults in the United States receiving albumin has increased, with marked, and currently unexplained, geographic variability and variability by hospital size.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies

PURPOSE

Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database.

MATERIALS AND METHODS

This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database.

RESULTS

LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients.

CONCLUSIONS

We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.

A prospective clinical study evaluating the development of bowel wall edema during laparoscopic and open visceral surgery

BACKGROUND

To examine bowel wall edema development in laparoscopic and open major visceral surgery.

METHODS

In a prospective study, 47 consecutively operated patients with gastric and pancreatic resections were included. Twenty-seven patients were operated in a conventional open procedure (open group) and 20 in a laparoscopic fashion (lap group). In all procedures, a small jejunal segment was resected during standard preparation, of which we measured the dry-wet ratio. Furthermore, HE staining was performed for measuring of bowel wall thickness and edema assessment.

RESULTS

Mean value (±std) of dry-wet ratio was significantly lower in the open than in the lap group (0.169 ± 0.017 versus 0.179 ± 0.015; p = 0.03) with the same amount of fluid administration in both groups and a longer infusion interval during laparoscopic surgery. Subgroup analyses (only pancreatic resections) still showed similar results. Histologic examination depicted a significantly larger bowel wall thickness in the open group.

CONCLUSIONS

Laparoscopic surgery does not seem to lead to the bowel wall edema observed to occur in open surgery regardless of the degree of intravenous fluid administration, thus supporting its use even in major visceral surgery.

Can surgical performance benchmarking be generalized across multiple outcomes databases: a comparison of University HealthSystem Consortium and National Surgical Quality Improvement Program

BACKGROUND

Surgeon's performance is tracked using patient outcomes databases. We compared data on patients undergoing laparoscopic cholecystectomy from 2 large databases with significant institutional overlap to see if either patient characteristics or outcomes were similar enough to accurately compare performance.

METHODS

Data from 2009 to 2011 were collected from University HealthSystem Consortium (UHC) and National Surgical Quality Improvement Program (NSQIP). UHC and NSQIP collect data from over 200 and 400 medical centers, respectively, with an overlap of 70. Patient demographics, pre-existing medical conditions, operative details, and outcomes were compared.

RESULTS

Fifty-six thousand one hundred ninety-seven UHC patients and 56,197 NSQIP patients met criteria. Groups were matched by age, sex, and pre-existing comorbidities. Outcomes for NSQIP and UHC differed, including mortality (.20% NSQIP vs .12% UHC; P < .0001), morbidity (2.0% vs 1.5%; P < .0001), wound infection (.07% vs .33%; P < .0001), pneumonia (.38% vs .75%; P < .0001), urinary tract infections (.62% vs .01%; P < .0001), and length of hospital stay (1.8 ± 7.5 vs 3.8 ± 3.7 days; P = .0004), respectively.

CONCLUSIONS

Surgical outcomes are significantly different between databases and resulting performance data may be significantly biased. A single unified national database may be required to correct this problem.

Alvimopan reduces length of stay and costs in patients undergoing segmental colonic resections: results from multicenter national administrative database

BACKGROUND

Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, has been shown to expedite recovery of bowel function after colon resection surgery. Most data are available from industry-sponsored trials. This study aims to evaluate the clinical impact of this drug on perioperative outcomes and costs in patients undergoing segmental colonic resection for diverticular disease.

METHODS

A large administrative database maintained by the University Health System Consortium, an alliance of over 200 academic and affiliate hospitals, was queried from 2008 to 2011. International Classification of Diseases, 9th Revision, Clinical Modification codes for segmental colon resection because of diverticular disease were used to identify 2 matched cohorts of adult patients. University Health System Consortium's clinical resource manager was used to access pharmacy data and compare it with patient outcomes.

RESULTS

Five thousand two hundred ninety-nine patients met the above criteria. Four hundred thirty-eight patients received alvimopan and 4,861 did not. Regardless of laparoscopic or open approach, alvimopan significantly improved the postoperative length of stay (4.43 ± 2.02 vs 5.92 ± 3.79, P < .0001), cost (9,974 ± 4,077 vs 11,303 ± 6,968, P < .0001), and intensive care unit admission rate (1.83% vs 7.20%, P < .05), with no significant difference in mortality (.0% vs .19%, P = 1.000), morbidity (5.93% vs 8.39%, P = .08), or 30-day readmission rate (4.40% vs 4.63%, P = .90).

CONCLUSIONS

Alvimopan significantly reduced length of stay, days in the intensive care unit, and hospital cost for patients undergoing colonic segmental resections. Unlike some previously reported studies, we also observed a significant reduction in the length of stay in patients undergoing laparoscopic colectomies who received the drug. Alvimopan may reduce total healthcare costs if used as part of a best care practice model for colon resections.

Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections

BACKGROUND

The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities.

METHODS

We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n=14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression.

RESULTS

There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p<0.01) and fewer deaths (4% vs. 23%; p<0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1).

CONCLUSION

At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis

BACKGROUND

Conventional laparoscopic fundoplications (CLF) have been the gold standard for Nissen fundoplications (NFs) for two decades. The advent of a robotic approach for fundoplication procedures creates a potential alternative. Thus, we used a national database to examine perioperative outcomes with respect to open, laparoscopic, and robotic approaches.

METHODS

The University Health System Consortium is an alliance of medical centers, numbering over 115 academic institutions and their 271 affiliated hospitals. We used International Classification of Diseases codes to elicit patients over the age of 18 years who received NF procedures.

RESULTS

A total of 12,079 patients of similar demographic background received fundoplication procedures from October 2008 to June 2012. Of those, 2,168 were open fundoplications (OF), 9,572 were CLF, and 339 were robot-assisted laparoscopic fundoplications (RLF). CLF and RLF displayed no significance in mortality (0.1 vs. 0 %; p = 0.5489), morbidity (4.0 vs. 5.6 %; p = 0.1744), length of stay (2.8 ± 3.6 vs. 3.0 ± 3.5; p = 0.3242), and intensive care unit (ICU) cases (8.4 vs. 11.5 %; p = 0.051). However, CLF remained superior, with a lower 30-day re-admission rate (1.8 vs. 3.6 %; p < 0.05) and cost (US$7,968 ± 6,969 vs. US$10,644 ± 6,041; p < 0.05). When RLF was compared with OF, RLF had significantly improved morbidity (5.6 vs. 11 %; p < 0.05), length of stay (6.1 ± 7.2 vs. 3.0 ± 3.5 days; p < 0.05), less ICU admission (11.5 vs. 23.1 %; p <0.05) and less cost (US$10,644 ± 6,041 vs. US$12,766 ± 13,982; p < 0.05).

CONCLUSIONS

Current data suggests that robot-assisted NF procedures have similar patient outcomes to conventional laparoscopic NF, with the exception of added cost and higher re-admission rate. While the higher costs are expected given the new technology, increasing re-admission rates are concerning and may represent the level of experience of the surgeon as well as the robotic learning curve.

Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

BACKGROUND

Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group.

METHODS

Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed.

RESULTS

A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure.

CONCLUSIONS

On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.

The evolving role of laparoscopy in colonic diverticular disease: a systematic review

BACKGROUND

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

RESULTS

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

CONCLUSIONS

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.

Feasibility and impact on surgical outcomes of modified double-stapling technique for patients undergoing laparoscopic anterior resection

BACKGROUND

Anastomotic leakage is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate the modified double-stapling technique (MDST), as an alternative for conventional double-stapling technique (DST), and whether it could reduce the anastomotic leakage rate in laparoscopic anterior resection (Lapa-AR).

STUDY DESIGN

Between March 2009 and October 2010, a total of 189 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectosigmoid colon were divided into the MDST group (n = 95) and the DST group (n = 94) according to the anastomotic technique. Data were analyzed retrospectively. Morbidity and anastomotic leakage rate were compared between the two groups.

RESULTS

Patient demographics, preoperative comorbidity, tumor size, stage, and operative details were comparable between the two groups. There was no difference in operation time between the two groups. The overall complication rate was significantly lower in the MDST group than in the DST group (3.2 vs. 10.6 %, p = 0.042), including anastomotic leakage rate (0 vs.4.6 %, p = 0.029). The anastomotic technique was the only factor associated with anastomotic leakage in univariate analysis.

CONCLUSIONS

Our comparative study demonstrates MDST to have better short-term outcome in reducing anastomotic leakage compared with DST. This technique could be an alternative approach to maximize the patients' benefit in laparoscopic anterior resection.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease

PURPOSE

Laparoscopic-assisted sigmoidectomy is a widely applied technique in the operative treatment of diverticular disease. Treatment guidelines recommend operation of complicated diverticulitis and after recurrent attacks of uncomplicated diverticulitis. These guidelines have become subject to controversy. The objective of this study was to assess disease-related quality of life after laparoscopic sigmoidectomy.

METHODS

Data were collected retrospectively. Patients filled in a form describing their quality of life. All patients undergoing elective operation for diverticular disease between 1999 and 2006 at the Department of Surgery of the Uster Hospital, a regional medical center in Switzerland were included. The measurement tool we used is the Gastrointestinal Quality of Life Index (GIQLI). Wilcoxon-Mann-Whitney test or unpaired t-tests were applied to determine statistical significance of differences observed.

RESULTS

A total of 130 patients were included and 120 questionnaires were available for analysis. Mean follow-up was 40 months. Of the total, 48% reported a GIQLI >100 before the operation, which rose to 83% after the operation (p < 0.0001). Mean GIQLI was 95 before and 114 after the operation (p < 0.0001). Female patients reported lower GIQLI rates. Overall, 96% were satisfied with the operation.

CONCLUSIONS

The results in this study population show that in a majority of patients who underwent elective laparoscopic-assisted sigmoidectomy for recurrent diverticulitis gastrointestinal quality of life improved with the operation.

Laparoscopic colorectal cancer surgery by a colon lifting-up technique that decreases the number of access ports: comparison by propensity scoring of short-term and long-term outcomes with standard multiport laparoscopic surgery

BACKGROUND

Laparoscopic colectomy for colorectal cancer has become established as a minimally invasive surgical approach. However, many disposable instruments are required, and there is an associated disadvantage of cost. We have developed a new technique, which uses a suture string to lift up the colon. This method is expected to reduce the number of access ports required without compromising the radical cure.

OPERATIVE PROCEDURE

A suture string piercing the abdominal wall is passed through the mesocolon. The colon is retracted anteriorly and is fixed at the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is performed easily by a medial approach. The working space is more stable because the colon is fixed to the abdominal wall.

METHODS

This study examined the short-term and long-term surgical outcomes of laparoscopic resection for colorectal cancer using our colon lifting-up technique (CLT), compared with the standard multiport technique. The study design was a case-matched control by propensity scoring. Analyzed variables were sex, age, American Society of Anesthesiologists score, cancer in a different organ, multiple colorectal cancer, operator, operative year, tumor location, operative procedure, adjuvant chemotherapy, and International Union Against Cancer TNM stage.

RESULTS

From 2000 to 2010, 301 patients underwent CLT and 436 standard multiport technique, 148 patients were matched by propensity score and analyzed. Regarding short-term outcomes, there was no difference between the 2 groups. The mean number of ports needed was 3.37±0.48 for CLT (93 with 3 ports, 55 with 4). There were no differences in recurrence-free survival and overall survival in long-term follow-up results for each stage. There were neither recurrences nor complications due to CLT.

CONCLUSIONS

The CLT facilitated laparoscopic colectomy without compromising cure rates. It is a useful method to keep a stable view and to conserve medical resources.

Outcomes of right vs. left colectomy for colon cancer

BACKGROUND

Right colectomy (RC) is generally believed to be a simpler operation with better outcomes than left colectomy (LC). Our study was primarily intended to compare patient characteristics and perioperative outcomes between RC and LC in colon cancer patients, and secondarily to identify factors that increase the risk of developing postoperative abdominal abscess and/or anastomotic leak.

METHODS

Using the 2007 Nationwide Inpatient Sample database, we evaluated patients who underwent elective RC and LC for colon cancer.

RESULTS

A total of 50,799 patients underwent elective RC and LC for malignancy during 2007 (RC, 63.5%; LC, 36.5%). Overall, 9.6% were performed laparoscopically (RC, 9.7% vs. LC, 9.5%, P = 0.39). The majority of patients were Caucasian; 54.2% of RC and 46.5% LC patients were female (P < 0.01). RC patients were older (mean age, 70.8 vs. 65.8 years, P < 0.01) and had more comorbidities. While LC had more overall intraoperative complications (RC, 0.30% vs. LC, 1.32%, P < 0.01), RC had higher overall incidence of postoperative complications (28.43% vs. 26.75%, P < 0.01). Mean length of hospital stay (RC, 7.37 days vs. LC, 7.38 days) and in-hospital mortality (RC, 1.37% vs. LC, 1.49%) were similar in both groups. Multivariate analysis identified Native American race [adjusted odd ratio (AOR), 2.02], chronic renal failure (AOR, 1.97), congestive heart failure (AOR, 1.72), chronic pulmonary disease (AOR, 1.40), metastatic disease (AOR, 1.34), male gender (AOR, 1.23), and LC (AOR, 1.12) all independently increased the risk of abscess and/or leak.

CONCLUSIONS

RC patients were older and had more comorbidities and postoperative complications. Patient characteristics and comorbidities were more important in determining overall postoperative complications than anastomotic types.

Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection

BACKGROUND

The aim of this study was to retrospectively compare the outcomes of laparoscopic abdominoperineal resection (APR) and open APR.

METHODS

A multicenter, retrospective analysis was performed. The University HealthSystem Consortium database was accessed and searched for International Classification of Diseases, Ninth Revision, codes between October 2008 and January 2010. Discharge data were collected on patients undergoing laparoscopic APR and open APR.

RESULTS

Six hundred sixty-seven patients underwent laparoscopic APR, and 2,443 underwent open APR. When lower risk patient groups with minor or moderate severity of illness were compared, laparoscopic APR showed lower morbidity, reduced length of stay, reduced cost, and reduced incidence of intensive care unit admission. Comparative analysis showed no significant difference in mortality rate or 30-day readmission. When higher risk patients were compared, there were significantly reduced costs and reduced incidence of intensive care unit cases in the laparoscopic group.

CONCLUSIONS

Patients undergoing laparoscopic APR had overall superior perioperative outcomes compared with those undergoing open APR. Laparoscopic APR demonstrates excellent perioperative outcomes in appropriately selected patients.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update

BACKGROUND

The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system.

METHODS

An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated.

RESULTS

One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%).

CONCLUSION

We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Comparison of short, long-term surgical outcomes and mid-term health-related quality of life after laparoscopic and open resection for colorectal cancer: a case-matched control study

BACKGROUND

A multicenter randomized study is high quality, but it is also true that there are differences between institutions. The quality of treatment is consistent in a single center so comparisons in a retrospective study can be matched for many variables.

METHODS

This single-center study examined short-term and long-term outcomes for colorectal cancer in 258 patients who underwent laparoscopic resection (LC) and 258 matched open resection (OC) cases. The health-related qualities of life (HRQOL) at 1-2 years after the operations in 62 patients (35 LC and 27 OC) were compared by SF-36.

RESULTS

The conversion rate was 5.0%. Mean follow-up periods in LC and OC were 62.3 and 62.1 months, respectively. Operation time was longer in LC than in OC, although the difference was not significant in the later period. Bleeding and postoperative stay were reduced in LC. The morbidity rate was 18.6% in LC and 26.4% in OC. The 5-year overall survival in LC and OC were 94.6% vs. 92.0% for stage I, 95.2% vs. 91.8% for stage II, and 80.9% vs. 79.1% for stage III, respectively. The corresponding 5-year disease-free survival were 94.0% vs. 88.4%, 92.1% vs. 84.0%, and 64.3% vs. 65.4%, respectively. Recurrence rates did not differ between groups. In the analysis of HRQOL scores, role physical, bodily pain, social functioning, role emotional, and physical component summary scores in LC were better than in OC.

CONCLUSIONS

In LC for colorectal cancer, short-term outcomes except operation time and mid-term HRQOL were better than in OC, and there were no adverse effects relating to long-term outcomes.

Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia

INTRODUCTION

There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity.

METHODS

The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC's Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n=1,390) or ED (n=492) during a 3-year period between 2006 and 2008.

RESULTS

Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p<0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p<0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p<0.001) and length of stay (2.23±1.78 LM vs. 4.88±4.42 days ED; p<0.001), but comparable cost ($9,539 LM vs. $8990 ED; p>0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p>0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p<0.001). However, the length of stay was significantly increased in the ED group (8.96±7.86 LM vs. 11.72±11.05 days ED; p=0.04).

CONCLUSION

In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.

Safety, efficacy, and cost-effectiveness of common laparoscopic procedures

BACKGROUND

Laparoscopic surgery has been shown to offer superior surgical outcomes for most abdominal surgical procedures. However, there is hardly any evidence on surgical outcomes with patient risk stratification. This study aimed to compare outcomes of common laparoscopic and open surgical procedures for varying illness severity.

METHODS

A retrospective analysis of surgical outcomes for six commonly performed surgical procedures including cholecystectomy, appendectomy, reflux surgery, gastric bypass surgery, ventral hernia repair, and colectomy was performed using the University HealthSystem Consortium (UHC) Clinical Database/Resource Manager (CDB/RM). The 3-year discharge data for the six commonly performed laparoscopic surgical procedures were analyzed for outcome measures including observed mortality, overall patient morbidity, intensive care unit (ICU) admissions, 30-day readmissions, length of hospital stay, and hospital costs.

RESULTS

In this study, 208,314 patients underwent one of six common surgical procedures by either the open or the laparoscopic approach. Overall, the laparoscopic approach showed significantly lower mortality, reduced morbidity, fewer ICU admissions and 30-day readmissions, shorter hospital stay, and significantly reduced hospital costs for all the procedures. At stratification by illness severity, the laparoscopic group showed better or comparable surgical outcomes across all the illness severity groups. However, the observed mortality was comparable for the minor and moderate severity patients between laparoscopic and open surgery for most procedures. The 30-day readmission rate for major/extreme severity patients was comparable between the two groups for most surgical procedures.

CONCLUSIONS

This study demonstrated the superiority of laparoscopy over conventional open surgery across all illness severity risk groups for common surgical procedures. The results in general show that laparoscopic surgery is safe, efficacious, and cost-effective compared with open surgery and suggest that laparoscopic surgery should be the procedure of choice for all common surgical procedures, regardless of illness severity.

Laparoscopic surgery for colorectal cancer

Laparoscopic surgery as an alternative to traditional open surgery, has been accepted by an increasing number of surgeons and patients. In this paper, we review the advances in laparoscopic surgery for colorectal cancer and summarize its pros and cons by comparing with open surgery, including patient inclusion and exclusion, intraoperative outcomes, and short- and long-term outcomes. Furthermore, we provide an initial overview of the Da Vinci robotic system and the single-port laparoscopic surgery.

Current indications and role of surgery in the management of sigmoid diverticulitis

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

Opportunity cost: a systematic application to surgery

BACKGROUND

Opportunity cost is the potential gain or loss when a person chooses to perform an activity over its next best alternative. With respect to surgery, opportunity cost can occur if a less efficient technology uses more operating time than its next best alternative. This additional operating time could be used in a productive way that, when economically valued, adds a "cost" to the less efficient technology. Although fundamental to the economist's view of costs and widely used in economic assessments, opportunity cost analysis is infrequently used in economic evaluation of surgical technology. Previous cost comparison studies in the surgical literature have not addressed opportunity cost when estimating the efficiency of competing technologies. With increasing healthcare costs and new technologic advancements in surgery, a surgeon's ability to understand opportunity cost and apply it when choosing between two comparable technologies is essential. Our objective is to present a system to estimate the opportunity cost for given surgical specialties and present a model to demonstrate its principle.

METHODS

To demonstrate the principle of opportunity cost, our model used a hypothetical scenario comparing two clinically equivalent technologies that differed in that the use of one device (Device A) extended operating time in a hypothetical procedure by 30 minutes compared to its competitor device (Device B). How this extra operating time could potentially be used was then valued using the opportunity cost calculated by our study design. Our study design included 5 surgical procedures from 5 surgical specialties that were elective, profitable, high-volume (performed more than 100 times per year), and had a duration of less than 240 minutes. The data were taken from a university hospital setting in 2007 and included procedure volume, profit margin, and duration. The outcome measure was opportunity cost, which was estimated by dividing the selected procedure's profit margin by its duration.

RESULTS

Surgical specialty results are presented in the accompanying Tables. Otolaryngology has the highest opportunity cost at $38/min. This cost was calculated by using myringotomy as the procedure that was elective, short in duration, performed in high volume, and provided the highest profit margin. By applying our model, the otolaryngology surgeon using the less efficient Device A to perform a hypothetical procedure would incur an opportunity cost of $1,140 ($38/min x 30 min). This is because he could have performed additional myringotomy procedures in the time saved had he instead used the more efficient Device B in his hypothetical cases. General surgery has the lowest opportunity cost at $9/min; laparoscopic inguinal hernia repair was the procedure used for its calculation. Under the same model, the general surgeon using Device A would incur an opportunity cost of $270 ($9/min x 30 min). This is because the general surgeon could have performed additional laparoscopic femoral/hernia repairs had she used the more efficient Device B in her hypothetical cases.

CONCLUSION

In acknowledging opportunity cost, a surgeon can more accurately compare the efficiency of competing surgical devices. This comparison is carried out by estimating and applying a dollar amount to the potential utility of time created by the use of the less efficient device.

Supplementation of endoscopic submucosal dissection with sentinel node biopsy performed by natural orifice transluminal endoscopic surgery (NOTES) (with video)

BACKGROUND

Endoscopic submucosal dissection (ESD) is proving to be effective for the resection of selected early gastric and colon cancers. Its application and appropriateness could be extended if a means of determining lymphatic dissemination without recourse to a conventional operation could be provided.

OBJECTIVE

To demonstrate the feasibility of companion sentinel node biopsy (SNB) by natural orifice transluminal endoscopic surgery (NOTES) concurrent with intraluminal ESD in both the sigmoid colon and stomach.

DESIGN

Acute porcine model.

INTERVENTION

Arbitrarily selected mucosal foci were targeted for combined NOTES-SNB and ESD in the sigmoid and stomach of 2 separate anesthetized animals. NOTES peritoneal access was obtained either transgastrically or transvaginally. A second intraluminal endoscope was passed either orally or rectally, as appropriate, to perform submucosal injection for lymphatic mapping under direct vision of the NOTES endoscope. This endoscope then identified the first-order draining (sentinel) nodes and allowed their excisional biopsy. The sigmoid was retracted by magnetic assistance as required, while torque of an intraluminal gastroscope manipulated the stomach. After retrieval of the nodes, 1-cm and 1.5-cm specimens were resected from the sigmoid and stomach, respectively, by conventional ESD. At procedure end, necropsy was performed.

RESULTS

All sentinel nodes were identified, underwent biopsy, and were retrieved intact. ESD was subsequently readily performed without complication. SNB completeness and ESD quality were confirmed postprocedure.

LIMITATIONS

Experimental model with limited sample size.

CONCLUSIONS

Although not yet appropriate for human use, this proposal merits serious consideration as a potential means of augmenting the effectiveness and appropriateness of ESD techniques for GI neoplasia.

Deep and organ/space infections in patients undergoing elective colorectal surgery: incidence and impact on hospital length of stay and costs

BACKGROUND

The reported incidence of infection complicating elective colorectal surgery (ECS) is 11% to 26%. We evaluated length of stay (LOS) and expense associated with such infections, which heretofore remain unexplored.

METHODS

We reviewed 1127 ECS procedures from October 2005 to may 2007 to identify infected case subjects (n = 46). Data were obtained by way of chart abstraction and administrative database review. A case-control study evaluated LOS and actual accounting costs for case subjects versus uninfected control subjects (n = 46). Logistic regression determined risk factors for infection.

RESULTS

Infection incidence was 4.1%. Mean +/- SD LOS and costs were greater for case than control subjects: 21 +/- 15 days compared with 6 +/- 4 days (P < .001) and $42,516 +/- 39,972 compared with $10,999 +/- $7,122 (P < .001). Procedure type, infection, chronic obstructive pulmonary disease, increased age, and nonsmoking status predicted greater LOS and costs. Infection risk factors included duration of procedure > or =3 hours, male sex, higher American Society of Anesthesiologists (ASA) score, low baseline hematocrit, and indication for surgery of regional enteritis/ulcerative colitis.

COMMENTS

Infection development after ECS is infrequent in our population, but it results in significantly poorer outcomes. Vigilant adherence to preventive guidelines, including those for antibiotic prophylaxis, is warranted.