A National Database Analysis Comparing the Nationwide Inpatient Sample and American College of Surgeons National Surgical Quality Improvement Program in Laparoscopic vs Open Colectomies: Inherent Variance May Impact Outcomes

American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator as a Predictor of Postoperative Outcomes After Adult Spinal Deformity Surgery: A Retrospective Cohort Analysis

BACKGROUND AND OBJECTIVES

In recent years, there has been an outpouring of scoring systems that were built to predict outcomes after various surgical procedures; however, research validating these studies in spinal surgery is quite limited. In this study, we evaluated the predictability of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) for various postoperative outcomes after spinal deformity surgery.

METHODS

A retrospective chart review was conducted to identify patients who underwent spinal deformity surgery at our hospital between January 1, 2014, and December 31, 2022. Demographic and clinical data necessary to use the ACS NSQIP SRC and postoperative outcomes were collected for these patients. Predictability was analyzed using the area under the curve (AUC) of receiver operating characteristic curves and Brier scores.

RESULTS

Among the 159 study patients, the mean age was 64.5 ± 9.5 years, mean body mass index was 31.9 ± 6.6, and 95 (59.7%) patients were women. The outcome most accurately predicted by the ACS NSQIP SRC was postoperative pneumonia (observed = 5.0% vs predicted = 3.2%, AUC = 0.75, Brier score = 0.05), but its predictability still fell below the acceptable threshold. Other outcomes that were underpredicted by the ACS NSQIP SRC were readmission within 30 days (observed = 13.8% vs predicted = 9.0%, AUC = 0.63, Brier score = 0.12), rate of discharge to nursing home or rehabilitation facilities (observed = 56.0% vs predicted = 46.6%, AUC = 0.59, Brier = 0.26), reoperation (observed 11.9% vs predicted 5.4%, AUC = 0.60, Brier = 0.11), surgical site infection (observed 9.4% vs predicted 3.5%, AUC = 0.61, Brier = 0.05), and any complication (observed 33.3% vs 19%, AUC = 0.65, Brier = 0.23). Predicted and observed length of stay were not significantly associated (β = 0.132, P = .47).

CONCLUSION

The ACS NSQIP SRC is a poor predictor of outcomes after spinal deformity surgery.

De Novo Natural Language Processing Algorithm Accurately Identifies Myxofibrosarcoma From Pathology Reports

BACKGROUND

Available codes in the ICD-10 do not accurately reflect soft tissue sarcoma diagnoses, and this can result in an underrepresentation of soft tissue sarcoma in databases. The National VA Database provides a unique opportunity for soft tissue sarcoma investigation because of the availability of all clinical results and pathology reports. In the setting of soft tissue sarcoma, natural language processing (NLP) has the potential to be applied to clinical documents such as pathology reports to identify soft tissue sarcoma independent of ICD codes, allowing sarcoma researchers to build more comprehensive databases capable of answering a myriad of research questions.

QUESTIONS/PURPOSES

(1) What proportion of patients with myxofibrosarcoma within the National VA Database would be missed by searching only by soft tissue sarcoma ICD codes? (2) Is a de novo NLP algorithm capable of analyzing pathology reports to accurately identify patients with myxofibrosarcoma?

METHODS

All pathology reports (10.7 million) in the national VA corporate data warehouse were identified from 2003 to 2022. Using the word-search functionality, reports from 403 veterans were found to contain the term "myxofibrosarcoma." The resulting pathology reports were manually reviewed to develop a gold-standard cohort that contained only those veterans with pathologist-confirmed myxofibrosarcoma diagnoses. The cohort had a mean ± SD age of 70 ± 12 years, and 96% (287 of 300) were men. Diagnosis codes were abstracted, and differences in appropriate ICD coding were compared. An NLP algorithm was iteratively refined and tested using confounders, negation, and emphasis terms for myxofibrosarcoma. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for the NLP-generated cohorts through comparison with the manually reviewed gold-standard cohorts.

RESULTS

The records of 27% (81 of 300) of myxofibrosarcoma patients within the VA database were missing a sarcoma ICD code. A de novo NLP algorithm more accurately (92% [276 of 300]) identified patients with myxofibrosarcoma compared with ICD codes (73% [219 of 300]) or basic word searches (74% [300 of 403]) (p < 0.001). Three final algorithm models were generated with accuracies ranging from 92% to 100%.

CONCLUSION

An NLP algorithm can identify patients with myxofibrosarcoma from pathology reports with high accuracy, which is an improvement over ICD-based cohort creation and simple word search. This algorithm is freely available on GitHub ( https://github.com/sarcoma-shark/myxofibrosarcoma-shark ) and is available to facilitate external validation and improvement through testing in other cohorts.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Inter-rater reliability of ACS-NSQIP colorectal procedure coding in Canada

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) uses Current Procedural Terminology (CPT) codes for risk-adjusted calculations. This study evaluates the inter-rater reliability of coding colorectal resections across Canada by ACS-NSQIP surgical clinical nurse reviewers (SCNR) and its impact on risk predictions.

METHODS

SCNRs in Canada were asked to code simulated operative reports. Percent agreement and free-marginal kappa correlation were calculated. The ACS-NSQIP risk calculator was utilized to illustrate its impact on risk prediction.

RESULTS

Responses from 44 of 150 (29.3 ​%) SCNRs revealed 3 to 6 different codes chosen per case, with agreement ranging from 6.7 ​% to 62.3 ​%. Free-marginal kappa correlation ranged from moderate agreement (0.53) to high disagreement (-0.17). ACS-NSQIP risk calculator predicted large absolute differences in risk for serious complications (0.2 ​%-13.7 ​%) and mortality (0.2 ​%-6.3 ​%).

CONCLUSION

This study demonstrated low inter-rater reliability in coding ACS-NSQIP colorectal procedures in Canada among SCNRs, impacting risk predictions.

A systematic review and meta-analysis of the effect of obesity on patients undergoing lower extremity revascularization

OBJECTIVE

In the present review, we assessed the effect of obesity on clinical outcomes for patients with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization surgery.

METHODS

A systematic search strategy of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was conducted. The included studies had compared obese and nonobese cohorts with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization. The outcomes included mortality, major adverse cardiovascular events, major adverse limb events, surgical site infections, endovascular access site complications, and perioperative complications.

RESULTS

Eight studies were included with 171,648 patients. The obese patients (body mass index ≥30 kg/m²) were more likely to be women, to have diabetes, and to have more cardiovascular comorbidities despite being younger. No association was found between obesity and peripheral arterial disease severity. Obesity was associated with an overall 22% decreased mortality risk after lower extremity revascularization (risk ratio [RR], 0.78; 95% confidence interval [CI], 0.71-0.85; P < .001; I² = 0%; GRADE (grading of recommendations assessment, development, evaluation), very low quality). A subgroup analysis by intervention type showed similar findings (endovascular: RR, 0.79; 95% CI, 0.71-0.87; P < .001; I² = 0%; open: RR, 0.70; 95% CI, 0.51-0.95; P = .024; I² = 43%). Obesity was associated with a 14% decreased risk of major adverse cardiovascular events for open surgery only (RR, 0.86; 95% CI, 0.76-0.98; P = .021; I² = 0%; GRADE, very low quality). Obesity was associated with an increased risk of surgical site infections pooled across intervention types (RR, 1.69; 95% CI, 1.34-2.14; P < .001; I² = 78%; GRADE, very low quality). No association was found between obesity and major adverse limb events (RR, 1.02; 95% CI, 0.93-1.11; P = .73; I² = 15%; GRADE, very low quality) or endovascular access site complications (RR, 1.11; 95% CI, 0.76-1.63; P = .58; I² = 86%; GRADE, very low quality). Pooled perioperative complications did not differ between the obese and nonobese cohorts (RR, 1.04; 95% CI, 0.84-1.28; P = .73; I² = 92%; GRADE, very low quality).

CONCLUSIONS

Obesity was associated with reduced mortality risk with both endovascular and open surgery, although a reduction in major adverse cardiovascular events was only observed with open surgery. In addition, obese patients had an increased risk of surgical site infections. Obesity was not associated with major adverse limb events, endovascular access site complications, or perioperative complications. The GRADE quality of evidence was very low. The findings from the present review suggest a survival advantage for obese patients with peripheral arterial disease. Future studies could focus on prospectively investigating the effect of obesity on peripheral arterial disease outcomes. A nuanced evaluation of body mass index as a preoperative risk factor is warranted.

Laparoscopic surgery for colorectal cancer in an elderly population with high comorbidity: a single centre experience

PURPOSE

The use of laparoscopic surgery for colorectal cancer in elderly patients with high comorbidity is a controversial subject. This retrospective analysis aims to compare two different age groups with respect to short and long term clinical and oncological outcomes.

METHODS

All laparoscopic colorectal resections for cancer performed between February 2011 and October 2017 with curative or palliative intention were evaluated.

RESULTS

Among 128 completed resections, the rate of major complications, length of hospital stays, 30-day mortality, 2-year recurrence rate, and the survival after palliative surgery were comparable between group A (< 75 years; n = 76) and B (≥ 75 years; n = 52). Patients in group B showed an extraordinarily high proportion of ASA III stage (73.1% vs. A: 35.5%; p < 0.01) and, in this context, an increased rate of minor postoperative complications (17.3% vs. A: 6.6%; p < 0.05) and lower overall 2 and 5-year survival rates. Within the first 2 years, they died sooner in the event of recurrence (57.1% vs. A: 18.2%; p < 0.05), and their survival after rectal resection, especially for low rectal carcinoma, was significantly reduced (58.8% vs. A: 96.7%; p < 0.001).

CONCLUSION

Laparoscopic surgery for colorectal cancer can be strongly advocated for elderly patients even in the face of high comorbidity. Whether very old patients with low rectal carcinoma also benefit from minimally invasive surgery or should undergo alternative therapies would need to be clarified primarily by examining the quality of life.

Cost-Effectiveness Analysis of Negative Pressure Wound Therapy to Prevent Surgical Site Infection After Elective Colorectal Surgery

BACKGROUND

Surgical site infection is common after colorectal surgery and is associated with increased costs. Prophylactic negative pressure wound therapy has previously been shown to reduce surgical site infection compared with conventional dressings. However, negative pressure wound therapy application is met with hesitancy because of its additional cost.

OBJECTIVE

This study aims to determine whether the application of prophylactic negative pressure wound therapy after elective colorectal surgery is cost-effective.

DESIGN

A cost-effectiveness analysis comparing prophylactic negative pressure wound therapy versus conventional dressing was completed using a Markov microsimulation model. A publicly funded single health care payer perspective was adopted across a lifetime horizon.

SETTING

This study was conducted using in-hospital elective colorectal surgery.

PATIENTS

The base case was an age-, sex-, and comorbidity-standardized patient undergoing open elective colorectal surgery.

INTERVENTION

Negative pressure wound therapy was applied postoperatively over closed incisions.

MAIN OUTCOMES

The primary outcomes of interest were the number of surgical site infections, total costs, and quality-adjusted life-years gained. Secondary outcomes included emergency department presentation, hospital readmission, nursing wound care utilization, fascial dehiscence, incisional hernia, and non-surgical site infection-related complications.

RESULTS

We found that prophylactic negative pressure wound therapy, standardized to 1000 patients, prevented 51 surgical site infections, 3 fascial dehiscences, 10 incisional hernias, 22 emergency department presentations, and 6 hospital readmissions. This resulted in a total cost saving of $17,066 and 92.2 quality-adjusted life-years gained ($17.07 and 0.09 quality-adjusted life-years gained on average per patient). When the patients' risk of surgical site infections was greater than 3.2%, negative pressure wound therapy was a cost-effective strategy at a willingness to pay of $50,000/quality-adjusted life-years.

LIMITATIONS

We did not model for societal perspective, emergent presentations of incarcerated hernias, or complications with hernia repair. The results of this model are reliant on the published negative pressure wound therapy efficacy and may change when additional data arise.

CONCLUSION

The use of negative pressure wound therapy is the dominant strategy with improved outcomes and reduced costs compared with conventional dressing in patients undergoing colorectal surgery, particularly in at-risk patients. See Video Abstract at http://links.lww.com/DCR/B782.

ANLISIS DE RENTABILIDAD DE LA TERAPIA DE PRESIN NEGATIVA PARA PREVENIR INFECCIN DEL SITIO QUIRRGICO DESPUS DE CIRUGA COLORRECTAL ELECTIVA

ANTECEDENTES:La infección del sitio quirúrgico es común después de la cirugía colorrectal y se asocia con un aumento de los costos. Anteriormente se demostró que la terapia profiláctica con presión negativa reduce la infección del sitio quirúrgico en comparación con los apósitos convencionales. Sin embargo, el uso de la terapia de presión negativa se encuentra en dudas debido a su costo adicional.OBJETIVO:Determinar si la aplicación de la terapia profiláctic con presión negativa después de la cirugía colorrectal electiva es rentable.DISEÑO:Se completó un análisis de costo-efectividad comparando la terapia profiláctica con presión negativa versus apósito convencional utilizando un modelo de microsimulación de Markov. Se adoptó una perspectiva de pagador único de asistencia sanitaria financiada con fondos públicos a lo largo de toda la vida.AJUSTE:Cirugía colorrectal electiva intrahospitalaria.PACIENTES:El caso base fue un paciente estandarizado por edad, sexo y comorbilidad sometido a cirugía colorrectal abierta electiva.INTERVENCIÓN:Aplicación postoperatoria de terapia de presión negativa sobre incisiones cerradas.RESULTADOS PRINCIPALES:Los resultados primarios de interés fueron el número de infecciones del sitio quirúrgico, los costos totales y los años de vida ganados ajustados por calidad. Los resultados secundarios incluyeron presentación en la sala de emergencias, reingreso al hospital, la utilización del cuidado de heridas por enfermería, dehiscencia fascial, hernia incisional y complicaciones relacionadas con infecciones del sitio no quirúrgico.RESULTADOS:Estandarizado para 1,000 pacientes, encontramos que la terapia profiláctica con presión negativa previno 51 infecciones del sitio quirúrgico, 3 dehiscencias fasciales, 10 hernias incisionales, 22 presentaciones en la sala de emergencias y 6 reingresos al hospital. Esto resultó en un ahorro total de costos de $ 17.066 y 92.2 años de vida ganados ajustados por calidad ($ 17.07 y 0.09 años de vida ganados ajustados por calidad en promedio por paciente). Cuando el riesgo de infección del sitio quirúrgico de los pacientes era superior al 3,2%, la terapia de presión negativa era una estrategia rentable con una disposición a pagar de 50.000 dólares por años de vida ajustados por calidad.LIMITACIONES:No modelamos para la perspectiva social, presentaciones emergentes de hernias encarceladas o complicaciones con la reparación de hernias. Los resultados de este modelo dependen de la eficacia publicada de la terapia de presión negativa y pueden cambiar cuando surjan más datos.CONCLUSIONES:El uso de la terapia de presión negativa es la estrategia dominante con mejores resultados y costos reducidos en comparación con el apósito convencional en pacientes sometidos a cirugía colorrectal, particularmente en pacientes de riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B782. (Traducción- Dr. Francisco M. Abarca-Rendon).

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

OBJECTIVES

To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database.

METHODS

We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors.

RESULTS

We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62 years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01).

CONCLUSION

In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

Predicting Risk of Perioperative Ischemic Optic Neuropathy in Spine Fusion Surgery: A Cohort Study Using the National Inpatient Sample

BACKGROUND

Ischemic optic neuropathy (ION) is a rare complication of anesthesia and surgery that causes vision loss in spine fusion. We sought to develop a predictive model based on known preoperative risk factors for perioperative ION to guide patient and physician preoperative decision-making.

METHODS

In the National Inpatient Sample (NIS) for 1998-2012, discharges for posterior thoracic, lumbar, and sacral spine fusion were identified and classified by ION status. Variables were selected without weighting via variable clustering using Principal Component Analysis of Mixed Data (PCA-MIX). Hierarchical clustering with 4 clusters was performed, and the variable with largest squared loading in each cluster was chosen. By splitting our sample into a training and testing data set, we developed and internally validated a predictive model. The final model using variables known preoperatively was constructed to allow determination of relative and absolute risk of developing perioperative ION and was tested for calibration and discrimination.

RESULTS

The final predictive model based on hierarchical clustering contained 3 preoperative factors, age, male or female sex, and the presence of obstructive sleep apnea (OSA). The predictive model based on these factors had an area under the receiver operating characteristic curve (AUC) of 0.65 and good calibration. A score cutoff of >1 had 100% sensitivity, while score of 3 had 96.5% specificity. The highest estimated absolute risk (844.5/million) and relative risk of ION (46.40) was for a man, age 40-64 years, with OSA.

CONCLUSIONS

The predictive model could enable screening for patients at higher risk of ION to provide more accurate risk assessment and surgical and anesthetic planning for perioperative ION in spine fusion.

Do prolonged operative times obviate the benefits associated with minimally invasive colectomy?

BACKGROUND

Minimally invasive colectomy is associated with improved length of stay and decreased postoperative morbidity. Little is known regarding the impact of prolonged operative time on the benefits afforded by minimally invasive colectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program procedure targeted colectomy dataset was queried to identify elective right and left colectomies performed between 2011 and 2017. Multivariable modeling was used to compare rates of composite 30-day death or serious morbidity, overall morbidity, mortality, anastomotic leak, surgical site infection, and length of stay for prolonged minimally invasive cases to those for average duration open cases.

RESULTS

A total of 16,602 right colectomies and 36,557 left colectomies were identified. Median operative times for open and minimally invasive right colectomies were 107 min and 129 min (P < .01), while that for open left colectomies was 128 min and 156 min for minimally invasive left colectomies (P < .01). Cohorts were stratified by quartiles of operative time with the highest (fourth) quartile defined as a prolonged operating time. When compared with an average duration open colectomy, prolonged minimally invasive right colectomies and left colectomies were associated with decreased risk-adjusted rates of overall morbidity, surgical site infection, and with lesser lengths of stay (P < .05). Prolonged minimally invasive left colectomies were also associated with improved rates of composite 30-day death or serious morbidity relative to average open left colectomies (odds ratio 0.66, 95% confidence interval, 0.54-0.79).

CONCLUSION

Prolonged operating times of an minimally invasive approach do not obviate the benefits of an minimally invasive approach to colectomy.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis

Background

Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction.

Methods

PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models.

Results

Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures.

Conclusions

Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0613-8) contains supplementary material, which is available to authorized users.

Antireflux Surgery in the USA: Influence of Surgical Volume on Perioperative Outcomes and Costs-Time for Centralization?

BACKGROUND

Few studies have analyzed the relationship between surgical volume and outcomes after antireflux procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs for patients undergoing surgery for gastroesophageal reflux disease.

METHODS

We analyzed the National Inpatient Sample (period 2000-2013). Adult patients (≥18 years old) with gastroesophageal reflux disease who underwent fundoplication were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (<10 operations/year), intermediate (10-25 operations/year), or high (>25 operations/year). We performed multivariable logistic regression models to assess the effect of surgical volume on patient outcomes.

RESULTS

The studied cohort comprised 75,544 patients who had antireflux surgery. When operations performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55 days longer, respectively). There was an increase in charges of 5120 dollars per patient at low-volume centers, and 4010 dollars per patient at intermediate-volume centers.

CONCLUSIONS

When antireflux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital stay is shorter, and costs for the healthcare system are decreased.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Laparoscopic Versus Open Surgery Still an Open Debate

Many would think that today minimally invasive surgery is the standard of care in the United States and that the conventional "open" approach would be relegated to few complex procedures or difficult redo operations. However, a great variability still exists in the utilization of laparoscopic surgery in the United States. This variability in surgical care of common diseases raises important ethical and economic issues and warrants a serious look by healthcare providers, insurance companies, and patients.

Outcomes after bariatric surgery according to large databases: a systematic review

PURPOSE

The rapid development of technological tools to record data allows storage of enormous datasets, often termed "big data". In the USA, three large databases have been developed to store data regarding surgical outcomes: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We aimed to evaluate the clinical impact of studies found in these databases concerning outcomes of bariatric surgery.

METHODS

We performed a systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines. Research carried out using the PubMed database identified 362 papers. All outcomes related to bariatric surgery were analysed.

RESULTS

Fifty-four studies, published between 2005 and February 2017, were included. These articles were divided into (1) outcomes related to surgical techniques (12 articles), (2) morbidity and mortality (12), (3) 30-day hospital readmission (10), (4) outcomes related to specific diseases (11), (5) training (2) and (6) socio-economic and ethnic observations in bariatric surgery (7). Forty-two papers were based on data from ACS-NSQIP, nine on data from NIS and three on data from MBSAQIP.

CONCLUSIONS

This review provides an overview of surgical management and outcomes of bariatric surgery in the USA. Large databases offer useful complementary information that could be considered external validation when strong evidence-based medicine data are lacking. They also allow us to evaluate infrequent situations for which randomized control trials are not feasible and add specific information that can complement the quality of surgical knowledge.

Paraesophageal Hernia Repair in the USA: Trends of Utilization Stratified by Surgical Volume and Consequent Impact on Perioperative Outcomes

BACKGROUND

The impact of surgical volume on perioperative results after a paraesophageal hernia (PEH) repair has not yet been analyzed. We sought to characterize the trend of utilization of this procedure stratified by surgical volume in the USA, and analyze its impact on perioperative outcomes.

METHODS

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥18 years old) who underwent PEH repair were included. Surgical volume was categorized as small (<6 operations/year), intermediate (6-20 operations/year), or high (>20 operations/year). Multivariable linear and logistic regression models were used to assess the effect of surgical volume on patient outcomes.

RESULTS

A total of 63,812 patients were included. Over time, the rate of procedures across high-volume centers increased from 65.8 to 94.4%. The use of the laparoscopic approach was significantly different among the groups (small volume 38.4%; intermediate volume 41.8%; high volume 67.4%; p < 0.0001). Patients undergoing PEH repair at high-volume hospitals were less likely to experience postoperative bleeding, cardiac failure, respiratory failure, and shock. On average, patients at low- and intermediate-volume hospitals stayed 0.8 and 0.6 days longer, respectively.

CONCLUSIONS

A spontaneous centralization towards high-volume centers for PEH repair has occurred in the last decade. This trend is beneficial for patients as it is associated with higher rates of laparoscopic operations, decreased surgical morbidity, and a shorter length of hospital stay.

Re-appraisal and consideration of minimally invasive surgery in colorectal cancer

Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.

Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Antireflux Surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) has proven to be as effective as open antireflux surgery (OARS), but it is associated with a shorter hospital stay and a faster recover. The aims of this study were to assess the national use of LARS in the US and to compare the perioperative outcomes between laparoscopic and open antireflux procedures in a national cohort.

STUDY DESIGN

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000 to 2013. The study included adult patients (18 years and older) diagnosed with gastroesophageal reflux disease (GERD), who underwent either laparoscopic or open fundoplication. Multivariable linear and logistic regression, adjusted for patient demographics, comorbidities, and hospital characteristics were used to assess the effect of the laparoscopic approach on patient outcomes.

RESULTS

A total of 75,544 patients were included, with 44,089 having LARS (58.4%) and 31,455 having OARS (41.6%). The rate of laparoscopic procedures increased from 24.8 LARS per 100 procedures in 2000, to 84.3 LARS per 100 procedures in 2013 (p < 0.0001). Patients undergoing laparoscopic surgery were less likely to experience postoperative venous thromboembolism, wound complications, infection, esophageal perforation, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. On average, the laparoscopic approach reduced length of stay by 2.1 days, and decreased hospital charges by $9,530.

CONCLUSIONS

The use of the laparoscopic approach for the surgical treatment of GERD has increased significantly in the last decade in the US. This approach is associated with lower morbidity and mortality, shorter hospital stay, and lower costs for the health care system.