1
|
Steffens D, McBride KE, Hirst N, Solomon MJ, Anderson T, Thanigasalam R, Leslie S, Karunaratne S, Bannon PG. Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system. J Robot Surg 2023; 17:2237-2245. [PMID: 37289337 PMCID: PMC10492768 DOI: 10.1007/s11701-023-01643-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/28/2023] [Indexed: 06/09/2023]
Abstract
This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.
Collapse
Affiliation(s)
- Daniel Steffens
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Kate E McBride
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia.
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.
| | - Nicholas Hirst
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Solomon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Teresa Anderson
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ruban Thanigasalam
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Scott Leslie
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Sascha Karunaratne
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul G Bannon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Missenden Road, PO Box M40, Sydney, NSW, 2050, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- The Baird Institute, Sydney, NSW, Australia
| |
Collapse
|
2
|
Larach JT, Flynn J, Tew M, Fernando D, Apte S, Mohan H, Kong J, McCormick JJ, Warrier SK, Heriot AG. Robotic versus laparoscopic proctectomy: a comparative study of short-term economic and clinical outcomes. Int J Colorectal Dis 2023; 38:161. [PMID: 37284889 PMCID: PMC10247549 DOI: 10.1007/s00384-023-04446-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Although several studies compare the clinical outcomes and costs of laparoscopic and robotic proctectomy, most of them reflect the outcomes of the utilisation of older generation robotic platforms. The aim of this study is to compare the financial and clinical outcomes of robotic and laparoscopic proctectomy within a public healthcare system, utilising a multi-quadrant platform. METHODS Consecutive patients undergoing laparoscopic and robotic proctectomy between January 2017 and June 2020 in a public quaternary centre were included. Demographic characteristics, baseline clinical, tumour and operative variables, perioperative, histopathological outcomes and costs were compared between the laparoscopic and robotic groups. Simple linear regression and generalised linear model analyses with gamma distribution and log-link function were used to determine the impact of the surgical approach on overall costs. RESULTS During the study period, 113 patients underwent minimally invasive proctectomy. Of these, 81 (71.7%) underwent a robotic proctectomy. A robotic approach was associated with a lower conversion rate (2.5% versus 21.8%;P = 0.002) at the expense of longer operating times (284 ± 83.4 versus 243 ± 89.8 min;P = 0.025). Regarding financial outcomes, robotic surgery was associated with increased theatre costs (A$23,019 ± 8235 versus A$15,525 ± 6382; P < 0.001) and overall costs (A$34,350 ± 14,770 versus A$26,083 ± 12,647; P = 0.003). Hospitalisation costs were similar between both approaches. An ASA ≥ 3, non-metastatic disease, low rectal cancer, neoadjuvant therapy, non-restorative resection, extended resection, and a robotic approach were identified as drivers of overall costs in the univariate analysis. However, after performing a multivariate analysis, a robotic approach was not identified as an independent driver of overall costs during the inpatient episode (P = 0.1). CONCLUSION Robotic proctectomy was associated with increased theatre costs but not with increased overall inpatient costs within a public healthcare setting. Conversion was less common for robotic proctectomy at the expense of increased operating time. Larger studies will be needed to confirm these findings and examine the cost-effectiveness of robotic proctectomy to further justify its penetration in the public healthcare system.
Collapse
Affiliation(s)
- José Tomás Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Julie Flynn
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
| | - Michelle Tew
- Health Economics, Department of Health Services Research, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Diharah Fernando
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Sameer Apte
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Helen Mohan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Joseph Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia.
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia.
| |
Collapse
|
3
|
Hayden DM, Korous KM, Brooks E, Tuuhetaufa F, King-Mullins EM, Martin AM, Grimes C, Rogers CR. Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2023; 37:3306-3320. [PMID: 36520224 PMCID: PMC10947550 DOI: 10.1007/s00464-022-09793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 11/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.
Collapse
Affiliation(s)
- Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin M Korous
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA
| | - Ellen Brooks
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | - Fa Tuuhetaufa
- University of Utah School of Medicine, Department of Family and Preventive Medicine, Salt Lake, UT, USA
| | | | - Abigail M Martin
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Chassidy Grimes
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Charles R Rogers
- Institute for Health and Equity, Medical College of Wisconsin, 1000 N. 92nd St, Milwaukee, WI, 53226, USA.
| |
Collapse
|
4
|
Diaz SE, Lee YF, Bastawrous AL, Shih IF, Lee SH, Li Y, Cleary RK. Comparison of health-care utilization and expenditures for minimally invasive vs. open colectomy for benign disease. Surg Endosc 2022; 36:7250-7258. [PMID: 35194661 PMCID: PMC9485164 DOI: 10.1007/s00464-022-09097-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/07/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Adoption of minimally invasive approaches continues to increase, and there is a need to reassess outcomes and cost. We aimed to compare open versus minimally invasive colectomy short- and long-term health-care utilization and payer/patient expenditures for benign disease. METHODS This is a retrospective analysis of IBM® MarketScan® Database patients who underwent left or right colectomy for benign disease between 2013 and 2018. Outcomes included total health-care expenditures, resource utilization, and direct workdays lost up to 365 days following colectomy. The open surgical approach (OS) was compared to minimally invasive colectomy (MIS) with subgroup analysis of laparoscopic (LS) and robotic (RS) approaches using inverse probability of treatment weighting. RESULTS Of 10,439 patients, 2531 (24.3%) had open, 6826 (65.4%) had laparoscopic, and 1082 (10.3%) had robotic colectomy. MIS patients had shorter length of stay (LOS; mean difference, - 1.71, p < 0.001) and lower average total expenditures (mean difference, - $2378, p < 0.001) compared with open patients during the index hospitalization. At 1 year, MIS patients had lower readmission rates, and fewer mean emergency and outpatient department visits than open patients, translating into additional savings of $5759 and 2.22 fewer days missed from work for health-care visits over the 365-day post-discharge period. Within MIS, RS patients had shorter LOS (mean difference, - 0.60, p < 0.001) and lower conversion-to-open rates (odds ratio, 0.31 p < 0.001) during the index hospitalization, and lower hospital outpatient visits (mean difference, - 0.31, p = 0.001) at 365 days than LS. CONCLUSION MIS colectomy is associated with lower mean health-care expenditures and less resource utilization compared to the open approach for benign disease at index operation and 365-days post-discharge. Health-care expenditures for LS and RS are similar but shorter mean LOS and lower conversion-to-open surgery rates were observed at index operation for the RS approach.
Collapse
Affiliation(s)
- Sarah E. Diaz
- grid.416444.70000 0004 0370 2980Department of Surgery, St Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI 48106 USA
| | - Yongjin F. Lee
- grid.281044.b0000 0004 0463 5388Swedish Cancer Institute, Seattle, WA USA
| | - Amir L. Bastawrous
- grid.281044.b0000 0004 0463 5388Swedish Cancer Institute, Seattle, WA USA
| | - I.-Fan Shih
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Shih-Hao Lee
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Yanli Li
- grid.420371.30000 0004 0417 4585Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA USA
| | - Robert K. Cleary
- grid.416444.70000 0004 0370 2980Department of Surgery, St Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI 48106 USA
| |
Collapse
|
5
|
Gunnells D, Cannon J. Robotic Surgery in Crohn's Disease. Clin Colon Rectal Surg 2021; 34:286-291. [PMID: 34512197 DOI: 10.1055/s-0041-1729862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery for Crohn's disease presents unique challenges secondary to the inflammatory nature of the disease. While a minimally invasive approach to colorectal surgery has consistently been associated with better patient outcomes, adoption of laparoscopy in Crohn's disease has been limited due to these challenges. Robotic assisted surgery has the potential to overcome these challenges and allow more complex patients to undergo a minimally invasive operation. Here we describe our approach to robotic assisted surgery for terminal ileal Crohn's disease.
Collapse
Affiliation(s)
- Drew Gunnells
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| | - Jamie Cannon
- Division of Gastrointestinal Surgery, University of Alabama, Birmingham, Alabama
| |
Collapse
|
6
|
Real-world comparison of curative open, laparoscopic and robotic resections for sigmoid and rectal cancer-single center experience. J Robot Surg 2021; 16:315-321. [PMID: 33871771 DOI: 10.1007/s11701-021-01239-y] [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: 02/24/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
There has been an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. Aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Median age of population was 68 years (IQR 59-73), majority (68%) were males. Median distance from anal verge in the robotic surgery group was 8 cm, compared to 15 and 14.5 cm in the open and laparoscopic groups, respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7 cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.
Collapse
|
7
|
Optimizing outcomes in colorectal surgery: cost and clinical analysis of robotic versus laparoscopic approaches to colon resection. J Robot Surg 2021; 16:107-112. [PMID: 33634355 DOI: 10.1007/s11701-021-01205-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/25/2021] [Indexed: 01/18/2023]
Abstract
The use of robotics in colorectal surgery has been steadily increasing, however, reported longer operative times and increased cost has limited its widespread adoption. We investigated the cost of elective colorectal surgery based on type of anatomic resection and the impact of a standardized protocol for robotic colectomies. A retrospective review was conducted of 279 elective colectomies at a single institution between 2013 and 2017. Clinical outcomes and detailed cost data were compared based on open, laparoscopic, or robotic surgical approach and stratified by anatomic resection. Robotic, laparoscopic and open colectomy rates were 35, 34 and 31%, respectively. While total costs were similar in robotic and laparoscopic surgery, anatomic resection stratification showed that low anterior resection (LAR) was significantly cheaper ($14,093 vs $17,314). When a standardized surgical protocol was implemented for robotic colectomies, significant reductions in operative times, length of stay, total cost, and operative cost were observed. Robotic surgery may be most cost effective for elective LAR compared to laparoscopic or open approaches. A standardized surgical protocol for robotic surgery may help reduce costs by reducing operative times, operating rooms expenditure, and lengths of stay.
Collapse
|
8
|
Grass F, Merchea A, Mathis KL, Mishra N, Heien H, Sangaralingham LR, Larson DW. Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer. J Surg Oncol 2021; 123:1023-1029. [PMID: 33497477 DOI: 10.1002/jso.26390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. METHODS Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. RESULTS In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average $183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. CONCLUSION Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type.
Collapse
Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Switzerland
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nitin Mishra
- Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Herbert Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
9
|
Farkas N, Conroy M, Harris H, Kenny R, Baig MK. Hartmann's at 100: Relevant or redundant? Curr Probl Surg 2020; 58:100951. [PMID: 34392941 DOI: 10.1016/j.cpsurg.2020.100951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/15/2020] [Indexed: 01/02/2023]
Affiliation(s)
- Nicholas Farkas
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom.
| | - Michael Conroy
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Holly Harris
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Ross Kenny
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Mirza Khurrum Baig
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| |
Collapse
|
10
|
Osagiede O, Haehn DA, Spaulding AC, Otto N, Cochuyt JJ, Lemini R, Merchea A, Kelley S, Colibaseanu DT. Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review. Surg Endosc 2020; 35:5480-5488. [PMID: 32989545 DOI: 10.1007/s00464-020-08039-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/22/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.
Collapse
Affiliation(s)
- Osayande Osagiede
- Department of Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, NY, USA
| | | | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA. .,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.
| | - Nolan Otto
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, Fl, 32224, USA
| | - Riccardo Lemini
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Scott Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Jacksonville, FL, USA.,Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
11
|
Hospital robotic use for colorectal cancer care. J Robot Surg 2020; 15:561-569. [PMID: 32876922 DOI: 10.1007/s11701-020-01142-y] [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: 04/24/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.
Collapse
|
12
|
Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis. J Gastrointest Surg 2020; 24:1173-1182. [PMID: 31845141 DOI: 10.1007/s11605-019-04490-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach. METHODS The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat). RESULTS A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group. CONCLUSIONS Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.
Collapse
|
13
|
Cremades M, Ferret G, Parés D, Navinés J, Espin F, Pardo F, Caballero A, Viciano M, Julian JF. Telemedicine to follow patients in a general surgery department. A randomized controlled trial. Am J Surg 2020; 219:882-887. [PMID: 32252983 DOI: 10.1016/j.amjsurg.2020.03.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/13/2020] [Accepted: 03/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Telemedicine is becoming more popular in many medical specialties but few studies have been conducted in General Surgery. This study aims to evaluate the feasibility of its introduction in this specialty. METHODS A prospective randomized clinical trial (RCT) was conducted in 200 patients to compare conventional vs telemedicine follow-up in the outpatient clinics. The primary outcome was the feasibility of telemedicine follow-up and the secondary outcomes were its clinical impact and patient satisfaction. RESULTS Patients were enrolled between March 2017 and April 2018 and there were no statistically significant differences between the groups' characteristics. The primary outcome was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). No differences were found in clinical outcomes (P = 0.832) or patient satisfaction (P = 0.099). CONCLUSION Telemedicine is a good complementary service to facilitate follow-up management in selected patients from a General Surgery department.
Collapse
Affiliation(s)
- Manel Cremades
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain.
| | - Georgina Ferret
- General Surgery, Hospital Universitari Doctor Josep Trueta, Spain
| | - David Parés
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | - Jordi Navinés
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | - Franc Espin
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | - Fernando Pardo
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | - Albert Caballero
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | - Marta Viciano
- General Surgery, Hospital Universitari Germans Trias I Pujol, Spain
| | | |
Collapse
|
14
|
Roberts KE, Renee Hilton L, Friedman DT, Frieder JS, Zhang X, Duffy AJ. Safety and Feasibility of a Lower-Cost Stapler in Bariatric Surgery. Obes Surg 2019; 29:401-405. [PMID: 30411224 DOI: 10.1007/s11695-018-3580-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic staplers are integral to bariatric surgery. Their pricing significantly impacts the overall cost of procedures. An independent device company has designed a stapler handle and single-use reloads for cross-compatibility and equivalency with existing manufacturers, at a lower cost. OBJECTIVES We aim to demonstrate non-inferior function and cross-compatibility of a newly introduced stapler handle and reloads compared to our institution's current stapling system in a large animal survival study. SETTING University-affiliated animal research facility, USA. METHODS Matched small bowel anastomoses were created in four pigs, one with each stapler (a total of two per animal). After 14 days, investigators blinded to stapler type evaluated the anastomoses grossly and microscopically. Each anastomosis was scored on multiple measures of healing. Individual parameters were added for a global "healing score." RESULTS Clinical stapler function and gross quality of anastomoses were similar between stapler groups. Individual scores for anastomotic ulceration, reepithelialization, granulation tissue, mural healing, eosinophilic infiltration, serosal inflammation, and microscopic adherences were also statistically similar. The mean "healing scores" were equal. While this study was underpowered for subtle differences, safe and reliable performance in large animals still supports the feasibility of introducing new devices into human use. CONCLUSIONS The new stapler system delivers a similar technical performance and is cross-compatible with currently marketed stapling devices. An equivalent quality device at a lower price point should enable case cost reduction, helping to maintain hospital case margin and procedure value in the face of potentially declining reimbursement. This device may provide a safe and functional alternative to currently used laparoscopic surgical staplers.
Collapse
Affiliation(s)
- Kurt E Roberts
- Department of Surgery, Gastrointestinal Section, Yale University, 40 Temple Street, Suite 7B, New Haven, CT, 06510, USA
| | - L Renee Hilton
- Department of Surgery, Gastrointestinal Section, Yale University, 40 Temple Street, Suite 7B, New Haven, CT, 06510, USA.,Department of Surgery, Minimally Invasive and Digestive Diseases, Augusta University, Augusta, GA, USA
| | - Danielle T Friedman
- Department of Surgery, Gastrointestinal Section, Yale University, 40 Temple Street, Suite 7B, New Haven, CT, 06510, USA.
| | | | - Xuchen Zhang
- Department of Surgical Pathology, Yale University, New Haven, CT, 06520, USA
| | - Andrew J Duffy
- Department of Surgery, Gastrointestinal Section, Yale University, 40 Temple Street, Suite 7B, New Haven, CT, 06510, USA
| |
Collapse
|
15
|
Minimally invasive sigmoidectomy for diverticular disease decreases inpatient opioid use: Results of a propensity score-matched study. Am J Surg 2019; 220:421-427. [PMID: 31810518 DOI: 10.1016/j.amjsurg.2019.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/18/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients undergoing gastrointestinal surgery are at high risk for postoperative opioid use. METHODS We evaluated inpatient opioid use among patients undergoing sigmoidectomy for diverticular disease from the Premier Hospital Database and compared across surgical approaches using propensity score-matching analysis. RESULTS After the day of surgery, minimally invasive (MIS) patients were administered significantly lower doses of parenteral opioids (median daily morphine milligram equivalents [MME]: 33.3 versus 48.3, p < 0.001). Within MIS, significantly less parenteral opioids were used by the robotic-assisted (RS) than the laparoscopic (LS) group (median daily MME: 30.0 versus 36.8, p = 0.012). MIS patients were more likely than open to start oral opioids on the day of surgery (MIS vs. OS: 8.7% vs. 6.6%, p < 0.001; RS vs. LS: 12.6% vs. 10.2%, p = 0.048). CONCLUSION Minimally invasive sigmoidectomy for diverticular disease was associated with less postoperative parenteral opioid use and starting oral opioids sooner after surgery compared to the open approach.
Collapse
|
16
|
Ashley CW, Donaldson K, Evans KM, Nielsen B, Everett EN. Surgical Cross-Training With Surgery Naive Learners: Implications for Resident Training. JOURNAL OF SURGICAL EDUCATION 2019; 76:1469-1475. [PMID: 31303542 DOI: 10.1016/j.jsurg.2019.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/26/2019] [Accepted: 06/25/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE While current literature has explored the transferability of laparoscopic surgical skills to robotic surgery, this study looks to investigate the transferability of surgical skills between robotic surgical simulation and simulated traditional laparoscopy. DESIGN Participants completed a survey regarding prior surgery exposure and other confounding factors including previous video game experience and self-assessed hand-eye coordination. Following orientation to the laparoscopic simulator (LS) and robotic surgical simulator (RoSS), participants were timed performing the Balloon Grasp and Ball Drop tasks on the RoSS and the Peg Transfer and Ball Drop tasks on the LS. Participants were then randomized to either the laparoscopic or RoSS arm and timed performing the Ball Drop task 10 times and then reassessed performing the Ball Drop using the unpracticed modality. SETTING Clinical Simulation Laboratory at the University of Vermont PARTICIPANTS: A total of 31 medical students with limited experience in laparoscopic and robotic surgery. RESULTS There were no statistically significant differences in the demographics or prior surgical and videogame experience between the participants in the laparoscopic and robotic arms of the study (X2 = 0.72, p = 0.75). Timed initial assessment of the RoSS Balloon Grasp (p = 0.84) and Ball Drop (p = 0.79) tasks and the LS Peg Transfer (p = 0.14) and Ball Drop (p = 0.44) tasks were not statistically different between the 2 arms. The simulator modality which was practiced yielded the greatest improvement. The degree of improvement on the unpracticed modality was not statistically different between the groups (p = 0.57), and it was not significantly better than 2 rounds of sequential practice on the practiced modality (LS, p = 0.98 and RoSS, p = 0.55). CONCLUSIONS With practice, both groups increased surgical skill on the unpracticed modality. However, this degree of improvement was equal, suggesting there is no transferability of skills between laparoscopy and robotics.
Collapse
Affiliation(s)
- Charles W Ashley
- Department of Surgery, Gynecology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Katherine M Evans
- Department of Anesthesiology, University of Vermont College of Medicine, Burlington, Vermont
| | - Brian Nielsen
- Department of Obstetrics and Gynecology, Western Michigan University Homer Stryker M.D. College of Medicine, Kalamazoo, Michigan
| | - Elise N Everett
- Division of Gynecologic Oncology, University of Vermont College of Medicine, Burlington, Vermont.
| |
Collapse
|
17
|
Chen BP, Clymer JW, Turner AP, Ferko N. Global hospital and operative costs associated with various ventral cavity procedures: a comprehensive literature review and analysis across regions. J Med Econ 2019; 22:1210-1220. [PMID: 31456454 DOI: 10.1080/13696998.2019.1661680] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: The aim of this literature review was to provide a comprehensive report on hospital costs, and cost components, for a range of ventral cavity surgical procedures across three regions of focus: (1) Americas, (2) Europe, Middle East and Africa (EMEA), and (3) Asia-Pacific. Methods: A structured search was performed and utilized a combination of controlled vocabulary (e.g., "Hepatectomy", "Colectomy", "Costs and Cost Analysis") and keywords (e.g. "liver resection", "bowel removal", "economics"). Studies were considered eligible for inclusion if they reported hospital-related costs associated with the procedures of interest. Cost outcomes included operating room (OR) time costs, total OR costs, ward stay costs, total admission costs, OR cost per minute and ward cost per day. All costs were converted to 2018 USD. Results: Total admission costs were observed to be highest in the Americas, with an average cost of $15,791. The average OR time cost per minute was found to vary by region: $24.83 (Americas), $14.29 (Asia-Pacific), and $13.90 (EMEA). A cost-breakdown demonstrated that OR costs typically comprised close to 50%, or more, of hospital admission costs. This review also demonstrates that decreasing OR time by 30 min provides cost savings approximately equivalent to a 1-day reduction in ward time. Conclusion: This literature review provided a comprehensive assessment of hospital costs across various surgical procedures, approaches, and geographical regions. Our findings indicate that novel processes and healthcare technologies that aim to reduce resources such as operating time and hospital stay, can potentially provide resource savings for hospital payers.
Collapse
Affiliation(s)
- Brian P Chen
- Ethicon, Inc, a Johnson & Johnson Company , Somerville , NJ , USA
| | - Jeffrey W Clymer
- Ethicon, Inc, a Johnson & Johnson Company , Somerville , NJ , USA
| | | | - Nicole Ferko
- Cornerstone Research Group , Burlington , ON , Canada
| |
Collapse
|
18
|
Sigmoidectomy for Diverticulitis—A Propensity-Matched Comparison of Minimally Invasive Approaches. J Surg Res 2019; 243:434-439. [DOI: 10.1016/j.jss.2019.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/30/2019] [Accepted: 06/06/2019] [Indexed: 12/29/2022]
|
19
|
Osagiede O, Spaulding AC, Cochuyt JJ, Naessens JM, Merchea A, Crandall M, Colibaseanu DT. Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings. J Surg Res 2019; 243:75-82. [PMID: 31158727 DOI: 10.1016/j.jss.2019.04.089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/18/2019] [Accepted: 04/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings. METHODS This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded. RESULTS Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d). CONCLUSIONS Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.
Collapse
Affiliation(s)
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Amit Merchea
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Marie Crandall
- Department of Surgery, University of Florida, Jacksonville, Florida
| | | |
Collapse
|
20
|
Osagiede O, Spaulding AC, Cochuyt JJ, Naessens J, Merchea A, Colibaseanu DT. Trends in the Use of Laparoscopy and Robotics for Colorectal Cancer in Florida. J Laparoendosc Adv Surg Tech A 2019; 29:926-933. [PMID: 31094645 DOI: 10.1089/lap.2019.0016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.
Collapse
Affiliation(s)
| | - Aaron C Spaulding
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Jordan J Cochuyt
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - James Naessens
- 2 Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Amit Merchea
- 1 Department of Surgery and Mayo Clinic, Jacksonville, Florida
| | | |
Collapse
|
21
|
Minimally invasive colectomy is associated with reduced risk of anastomotic leak and other major perioperative complications and reduced hospital resource utilization as compared with open surgery: a retrospective population-based study of comparative effectiveness and trends of surgical approach. Surg Endosc 2019; 34:610-621. [DOI: 10.1007/s00464-019-06805-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 04/29/2019] [Indexed: 01/27/2023]
|
22
|
Robotic-assisted surgery for complicated and non-complicated diverticulitis: a single-surgeon case series. J Robot Surg 2019; 13:765-772. [DOI: 10.1007/s11701-018-00914-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/13/2018] [Indexed: 12/14/2022]
|
23
|
Batool F, Collins SD, Albright J, Ferraro J, Wu J, Krapohl GL, Campbell DA, Cleary RK. A Regional and National Database Comparison of Colorectal Outcomes. JSLS 2019; 22:JSLS.2018.00031. [PMID: 30410300 PMCID: PMC6203949 DOI: 10.4293/jsls.2018.00031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background and Objectives: The traditional open approach is still a common option for colectomy and the most common option chosen for rectal resections for cancer. Randomized trials and large database studies have reported the merits of the minimally invasive approach, while studies comparing laparoscopic and robotic options have reported inconsistent results. Methods: This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in protocol-driven regional and national databases. Logistic and multiple linear regression analyses were used to compare standard 30-day colorectal outcomes in the Michigan Surgical Quality Collaborative (MSQC) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases. The primary outcome was overall complications. Results: A total of 10,054 MSQC patients (open 37.5%, laparoscopic 48.8%, and robotic 13.6%) and 80,535 ACS-NSQIP patients (open 25.0%, laparoscopic 67.1%, and robotic 7.9%) met inclusion criteria. Overall complications and surgical site infections were significantly favorable for the laparoscopic and robotic approaches compared with the open approach. Anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach in ACS-NSQIP, while there was no significant difference between robotic and open approaches in MSQC. Laparoscopic complications were significantly less than robotic complications in MSQC but significantly more in ACS-NSQIP. Laparoscopic 30-day mortality was significantly less than for the robotic approach in MSQC, but there was no difference in ACS-NSQIP. Conclusion: Minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. Individual complication comparisons vary between databases, and caution should be exercised when interpreting results in context.
Collapse
Affiliation(s)
- Farwa Batool
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA
| | - Jeremy Albright
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Jane Ferraro
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Juan Wu
- Department of Academic Research, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan, USA
| | - Greta L Krapohl
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, Michign, USA
| | - Darrell A Campbell
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Ann Arbor, Ypsilanti, Michigan, USA
| |
Collapse
|
24
|
Osagiede O, Spaulding AC, Cochuyt JJ, Naessens JM, Merchea A, Kasi PM, Crandall M, Colibaseanu DT. Disparities in minimally invasive surgery for colorectal cancer in Florida. Am J Surg 2018; 218:293-301. [PMID: 30503514 DOI: 10.1016/j.amjsurg.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The cost of minimally invasive surgery (MIS) raises potential for racial and social disparities. The aim of this study was to identify the racial, socioeconomic and geographic disparities associated with MIS for colorectal cancer (CRC) in Florida. METHODS Using the Florida Inpatient Discharge Dataset, we examined the clinical data of patients who underwent elective resections for CRC during 2013-2015. Multivariable analysis was performed to identify differences in gender, age, race, urbanization, region, insurance and clinical characteristics associated with the surgical approach. RESULTS Of the 10,224 patients identified, 5308 (52%) had open surgery and 4916 (48%) had MIS. Females (p = 0.012), Medicare-insured patients (p = 0.001) and residents of South Florida were more likely to undergo MIS. Patients with Medicaid (p = 0.008), metastasis (p < 0.001) or 3-5 comorbidities (p = 0.004) had reduced likelihood of MIS. Hispanic patients in Southwest Florida had reduced likelihood of receiving MIS than whites (p < 0.017). Patients who underwent MIS had significantly reduced LOS (p < 0.001). CONCLUSIONS Consistent with national studies, MIS for CRC in Florida is associated with insurance status and geographic location. There are patient-level regional differences for racial disparities in MIS for CRC in Florida.
Collapse
Affiliation(s)
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Jordan J Cochuyt
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Amit Merchea
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Pashtoon M Kasi
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Marie Crandall
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | | |
Collapse
|
25
|
Cleary RK, Kassir A, Johnson CS, Bastawrous AL, Soliman MK, Marx DS, Giordano L, Reidy TJ, Parra-Davila E, Obias VJ, Carmichael JC, Pollock D, Pigazzi A. Intracorporeal versus extracorporeal anastomosis for minimally invasive right colectomy: A multi-center propensity score-matched comparison of outcomes. PLoS One 2018; 13:e0206277. [PMID: 30356298 PMCID: PMC6200279 DOI: 10.1371/journal.pone.0206277] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023] Open
Abstract
Background The primary objective of this study was to retrospectively compare short-term outcomes of intracorporeal versus extracorporeal anastomosis for minimally invasive laparoscopic and robotic-assisted right colectomies for benign and malignant disease. Recent studies suggest potential short-term outcomes advantages for the intracorporeal anastomosis technique. Methods This is a multicenter retrospective propensity score-matched comparison of intracorporeal and extracorporeal anastomosis techniques for laparoscopic and robotic-assisted right colectomy between January 11, 2010, and July 21, 2016. Results After propensity score-matching, there were a total of 1029 minimal invasive surgery cases for analysis—379 right colectomies (335 robotic-assisted and 44 laparoscopic) done with an intracorporeal anastomosis and 650 right colectomies (253 robotic-assisted and 397 laparoscopic) done with an extracorporeal anastomosis. There were no significant differences in any preoperative patient characteristics between groups. The minimally invasive intracorporeal anastomosis group had significantly longer operative times (p<0.0001), lower conversion to open rate (p = 0.01), shorter hospital length of stay (p = 0.02) and lower complication rate from after discharge to 30-days (p = 0.04) than the extracorporeal anastomosis group. Conclusions This comparison shows several clinical outcomes advantages for the intracorporeal anastomosis technique in minimally invasive right colectomy. These data may guide future refinements in minimally invasive training techniques and help surgeons choose among different minimally invasive options.
Collapse
Affiliation(s)
- Robert K. Cleary
- Department of Surgery, Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Andrew Kassir
- Colon and Rectal Clinic of Scottsdale, Scottsdale, Arizona, United States of America
| | - Craig S. Johnson
- Department of Surgery, Oklahoma Surgical Hospital, Tulsa, Oklahoma, United States of America
| | - Amir L. Bastawrous
- Swedish Colon and Rectal Clinic, Division of Colon and Rectal Surgery, Swedish Medical Center, Seattle, Washington, United States of America
| | - Mark K. Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida, United States of America
| | - Daryl S. Marx
- Department of Surgery, Monroe Surgical Hospital, Monroe, Louisiana, United States of America
| | - Luca Giordano
- Division of Gastrointestinal and Colorectal Surgery, Minimally Invasive and Robotic-assisted Surgery, and Bariatric Surgery, Jefferson Health Northeast Torresdale, Philadelphia, Pennsylvania, United States of America
| | - Tobi J. Reidy
- Department of Surgery, St. Francis Hospital and Health Centers, Franciscan Alliance, Indianapolis, Indiana, United States of America
| | - Eduardo Parra-Davila
- Department of Surgery, Celebration Center for Surgery, Florida Hospital Medical Group, Celebration, Florida, United States of America
| | - Vincent J. Obias
- Division of Colon and Rectal Surgery, George Washington University, Washington, District of Columbia, United States of America
| | - Joseph C. Carmichael
- Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Irvine, California, United States of America
| | - Darren Pollock
- Swedish Colon and Rectal Clinic, Division of Colon and Rectal Surgery, Swedish Medical Center, Seattle, Washington, United States of America
| | - Alessio Pigazzi
- Department of Surgery, Division of Colon and Rectal Surgery, University of California Irvine, Irvine, California, United States of America
| |
Collapse
|
26
|
Crolla RMPH, Mulder PG, van der Schelling GP. Does robotic rectal cancer surgery improve the results of experienced laparoscopic surgeons? An observational single institution study comparing 168 robotic assisted with 184 laparoscopic rectal resections. Surg Endosc 2018; 32:4562-4570. [DOI: 10.1007/s00464-018-6209-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 05/09/2018] [Indexed: 12/24/2022]
|
27
|
Disbrow DE, Pannell SM, Shanker BA, Albright J, Wu J, Bastawrous A, Soliman M, Ferraro J, Cleary RK. The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons. JOURNAL OF SURGICAL EDUCATION 2018; 75:767-778. [PMID: 29054345 DOI: 10.1016/j.jsurg.2017.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training. DESIGN An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort. SETTING/PARTICIPANTS This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States. RESULTS The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach. CONCLUSION The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.
Collapse
Affiliation(s)
- David E Disbrow
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Stephanie M Pannell
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Beth-Ann Shanker
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Jeremy Albright
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Juan Wu
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Amir Bastawrous
- Swedish Colon and Rectal Clinic, Swedish Cancer Institute, Swedish Medical Center, Seattle, Washington
| | - Mark Soliman
- Colon and Rectal Clinic of Orlando, Orlando, Florida
| | - Jane Ferraro
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan
| | - Robert K Cleary
- Colon and Rectal Surgery, St Joseph Mercy Hospital Ann Arbor, Ann Arbor, Michigan.
| |
Collapse
|
28
|
Holmer C, Kreis ME. Systematic review of robotic low anterior resection for rectal cancer. Surg Endosc 2017; 32:569-581. [DOI: 10.1007/s00464-017-5978-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/05/2017] [Indexed: 01/30/2023]
|
29
|
The cost of conversion in robotic and laparoscopic colorectal surgery. Surg Endosc 2017; 32:1515-1524. [PMID: 28916895 DOI: 10.1007/s00464-017-5839-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/22/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Conversion from minimally invasive to open colorectal surgery remains common and costly. Robotic colorectal surgery is associated with lower rates of conversion than laparoscopy, but institutions and payers remain concerned about equipment and implementation costs. Recognizing that reimbursement reform and bundled payments expand perspectives on cost to include the entire surgical episode, we evaluated the role of minimally invasive conversion in total payments. METHODS This is an observational study from a linked data registry including clinical data from the Michigan Surgical Quality Collaborative and payment data from the Michigan Value Collaborative between July 2012 and April 2015. We evaluated colorectal resections initiated with open and minimally invasive approaches, and compared reported risk-adjusted and price-standardized 30-day episode payments and their components. RESULTS We identified 1061 open, 1604 laparoscopic, and 275 robotic colorectal resections. Adjusted episode payments were significantly higher for open operations than for minimally invasive procedures completed without conversion ($19,489 vs. $15,518, p < 0.001). The conversion rate was significantly higher with laparoscopic than robotic operations (15.1 vs. 7.6%, p < 0.001). Adjusted episode payments for minimally invasive operations converted to open were significantly higher than for those completed by minimally invasive approaches ($18,098 vs. $15,518, p < 0.001). Payments for operations completed robotically were greater than those completed laparoscopically ($16,949 vs. $15,250, p < 0.001), but the difference was substantially decreased when conversion to open cases was included ($16,939 vs. $15,699, p = 0.041). CONCLUSION Episode payments for open colorectal surgery exceed both laparoscopic and robotic minimally invasive options. Conversion to open surgery significantly increases the payments associated with minimally invasive colorectal surgery. Because conversion rates in robotic colorectal operations are half of those in laparoscopy, the excess expenditures attributable to robotics are attenuated by consideration of the cost of conversions.
Collapse
|