Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database

BACKGROUND

Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States.

METHODS

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States.

RESULTS

A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%).

CONCLUSIONS

The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.

Predictive Factors of Acute Respiratory Failure in Esophagectomy for Esophageal Malignancy

Acute respiratory failure (ARespF) is a common complication after esophagectomy that contributes to higher morbidity and mortality. Using the Nationwide Inpatient Sample database, we sought to identify predictors of ARespF in 6352 patients who underwent esophagectomy for malignancy between 2006 and 2008. Multivariate regression analyses were performed to identify preoperative factors (patient characteristics, comorbidities, procedural type, tumor's location, hospital teaching status, and payer type) predictive of ARespF in esophagectomy. The overall rate of ARespF was 27.08 per cent. For comorbidities, independent risk factors for higher rate of ARF included weight loss (adjusted odds ratio [AOR], 3.63; 95% confidence interval [CI], 3.02 to 4.37), pulmonary hypertension (AOR, 2.38; 95% CI, 1.85 to 3.45), congestive heart failure (AOR, 2.35; 95% CI, 1.77 to 3.13), liver disease (AOR, 1.95; 95% CI, 1.22 to 3.12), chronic lung disease (AOR, 1.40; 95% CI, 1.17 to 1.66), and anemia (AOR, 1.26; 95% CI, 1.04 to 1.51). Cervical location of malignancy (AOR, 2.32; 95% CI, 1.51 to 3.56), total esophagectomy (AOR, 1.64; 95% CI, 1.41 to 1.90), and non-teaching hospital (AOR, 1.45; 95% CI, 1.20 to 1.75) were independent risk factors for ARespF. There was no effect of age, gender, race, hypertension, diabetes, renal failure, obesity, smoking, peripheral vascular disorder, or payer type on ARespF. We identified multiple preoperative risk factors that have an impact on development of ARespF after esophagectomy. Surgeons can use these factors to inform patients of potential risks and should consider these factors during surgical-decision making.

89 Antimicrobial Resistance Pattern and Prevalence of Extended Spectrum Beta-lactamase in Non-fermenting Gram Negative Bacteria, Isolated from Burn Wounds: A Prospective Study from a Tertiary Burn Center

Introduction

Burn wound infections are one of the major causes for long-term hospitalization and mortality among patients with thermal injuries. Identifying the bacterial cause of infection and determining the appropriate antibiotic to treat these infections is an important stage in treatment. The aim of this study was to investigate antimicrobial drug resistance in non-fermenting gram-negative bacteria isolated from burn wounds in patients who were admitted to a tertiary burn center.

Methods

In this prospective study during a six-month period in 2018,100 isolates of non-fermenting gram-negative bacteria were collected from 100 patients with thermal injuries. Antibiotic susceptibility test was performed using the Kirby-Bauer method based on the clinical and laboratory standards institute guidelines. Double-disc synergy test, a phenotypic method, was used to identify strains producing extended-spectrum beta-lactamase (ESBL). Data analyses were performed using SPSS.

Results

A total of 100 wound samples were examined from 100 patients, 76% were male and 24% were female with a mean age of 33 years (range 1–89 years old). Mean total body surface area burned was 35% (range 1–95%) and mean length of hospital stay was 24 days (range 3–69 days). Eighty five percent of cases were under 50 years old. Overall mortality rate in this study was 17%. The major causes of burn were liquefied natural gas tank explosion (35%) and scalds (19%). Acinetobacter baumannii (A.baumannii) was the most common pathogen followed by Pseudomonas aeruginosa (P.aeruginosa) (60% and 40%, respectively). ESBL producing rate was significantly higher in P.aeruginosa isolates (27.5%) than A.baumannii isolates (3.3%) (P-value < 0.001). Antibiotic resistance pattern of P.aeruginosa showed the highest resistance to ciprofloxacin, amikacin and imipenem (95%), followed by gentamicin (92.9%),ceftazidime(87.50) and piperacillin-tazobactam(85%). Antibiotic resistance pattern of A.baumannii showed the highest resistance to ceftazidime(100%) followed by ciprofloxacin, amikacin, imipenem(98.3%), gentamicin and piperacillin-tazobactam (93.3%). Multiple drug resistance (MDR) rate among A.baumannii and P.aeruginosa was 98.3% and 92.5% respectively, which is higher than previous reports.

Conclusions

A.baumannii and P.aeruginosa were the most common pathogens identified in this cohort with a significant MDR rate (over 95%). New strategies to control expansion of antimicrobial resistance in burn centers are necessary.

Applicability of Research to Practice

This study shows the antimicrobial resistance pattern and prevalence of ESBL in burn wounds indicating that further studies requires to identify new strategies to control emerging antimicrobial resistance in burn centers.

Effect of Anemia in Postoperative Outcomes of Autologous Breast Reconstruction Surgery

BACKGROUND

The true effects of anemia on postoperative surgical outcomes in autologous breast reconstruction surgery are unknown. We intended to evaluate the effect of chronic anemia on surgical outcomes in autologous breast reconstruction surgeries using a large national database.

METHODS

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed autologous breast reconstruction surgery from 2012 to 2014. Univariate and multivariate regression analyses were performed to independently evaluate the effect of chronic anemia on postoperative outcomes.

RESULTS

Totally, 55,839 patients underwent autologous breast reconstruction surgery (immediate: 40% vs. delayed: 60%) during this period. Overall, 6.0% of patients had chronic anemia at the time of surgery. Compared with patients without chronic anemia, patients with chronic anemia had a significantly higher complication rate (19.8% vs. 9.4%) and a longer mean length of hospital stay (5.4 vs. 3.7 days). Postoperative complications were significantly higher in patients with chronic anemia compared with patients without chronic anemia except for venous thromboembolism (VTE) and fat necrosis. Multivariate regression analyses demonstrated that chronic anemia was independently associated with an increased overall complication rate (adjusted odds ratio: 2.20). Also, multivariate regression analyses showed that chronic anemia was an independent risk factor of all the evaluated postoperative complications except VTE, stroke and fat necrosis.

CONCLUSION

This study demonstrated that chronic anemia was a significant predictor factor of morbidity in autologous breast reconstruction including flap failure. Correction of anemia prior to breast reconstruction may help reduce poor surgical outcomes related to chronic anemia.

Self-amputation of the Upper Extremity: A Case Report and Review of the Literature

Indications for upper-extremity replantation include wrist-level and wrist-proximal amputations, due to the devastating loss of function incurred from these severe injuries. Decisions regarding replantation must be made expeditiously at these proximal levels in an effort to minimize ischemia time. This decision-making process becomes more complicated when a patient presents following intentional self-amputation of an extremity, especially in the setting of an associated mood disorder, psychiatric illness, and/or frank psychosis. A case report is presented involving a 28-year-old right-hand dominant male with untreated depression and recent suicidal ideation who sustained a complete left forearm amputation (distal-third forearm-level) from a self-inflicted circular saw injury. We conducted a PubMed literature search of other reported cases of intentional self-amputations of the hand and upper extremity. The patient underwent replantation of the left upper extremity. At six years postoperatively, the patient was extremely satisfied with the appearance and function of the replanted extremity. Dash score was 5.8 with a Chen Grade 1 (excellent) functional recovery. A literature search identified 16 cases of self-inflicted upper extremity amputation. One patient died at the scene. 87% (13/15) of patients presenting to the hospital were diagnosed with a psychiatric disorder (depression n = 6, bipolar n = 2, and schizophrenia n = 5). 67% (10/15) of these patients were also diagnosed with psychosis. Ten patients underwent replantation (nine at hand/wrist level and one at forearm level), all of which were viable postoperatively. Detailed functional outcome data were not reported in any of the cases. Four patients (40%) were pleased or satisfied with the outcome, but subjective outcomes were not reported for the other six patients. Intentional self-amputation of the hand/upper extremity is an extreme and uncommon act, often presenting with complex psychiatric issues. Although replantation is technically feasible in this patient population, long-term subjective and objective functional outcomes are largely unknown. Future study of this unique group of patients is needed to better assess patient-reported outcomes and functional outcomes of replantation, which could help guide decision making at the time of initial injury. 

Frequency and Predictors of 30-Day Surgical Site Complications in Autologous Breast Reconstruction Surgery

BACKGROUND

Surgical site complication (SSC) is one of the known complications following autologous breast reconstruction. The aim of this study was to evaluate the frequency and predictors of 30-day surgical site complications in autologous breast reconstruction.

METHODS

American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database was used to identify patients who underwent autologous breast reconstruction during 2011-2015. Multivariate regression analysis was performed to identify independent perioperative risk factors of SSC.

RESULTS

Totally, 7,257 patients who underwent autologous breast reconstruction surgery were identified. The majority of the procedures were free flap (60%) versus pedicled flap (40%). The mean age was 51 years and the majority of patients were classified as American Society of Anesthesiologists (ASA)-II (60%) and 15% of patients had BMI>35. The overall 30-day SSC rate was 6.3%. The overall frequency of different types of SSC were superficial incisional infection (3.2%), wound dehiscence (1.8%), deep incisional infection (1.4%) and organ space infection (0.6%). BMI>35 (adjusted odds ratio [AOR]=2.38), smoking (AOR=2.0), diabetes mellitus (AOR=1.67) and hypertension (AOR=1.38) were significant risk factors of SSC. There was no association with age, ASA classification, steroid use, or reconstruction type.

CONCLUSION

The rate of 30-day SSC in autologous breast reconstruction was noticeable. The strongest independent risk factor for SSC in autologous breast reconstruction was BMI>35. The type of autologous breast reconstruction was not a predictive risk factor for SSC. Plastic surgeons should inform patients about their risk for SSC and optimizing these risk factors to minimize the rate of surgical site complications.

Outcomes of conversion of laparoscopic colorectal surgery to open surgery

Objectives:

There is limited data regarding the outcomes of patients who undergo conversion to open surgery during a laparoscopic operation in colorectal resection. We sought to identify the outcomes of such patients.

Methods:

The NIS (National Inpatient Sample) database was used to identify patients who had conversion from laparoscopic to open colorectal surgery during the 2009 to 2012 period. Multivariate regression analysis was performed to identify risk-adjusted outcomes of conversion to open surgery.

Results:

We sampled 776 007 patients who underwent colorectal resection. 337 732 (43.5%) of the patients had laparoscopic resection. Of these, 48 265 procedures (14.3%) were converted to open surgery. The mortality of converted patients was increased, when compared with successfully completed laparoscopic operations, but was still lower than that of open procedures (0.6% vs. 1.4% vs. 3.9%, respectively; adjusted odds ratio [AOR], 1.61 and 0.58, respectively; P < .01). The most common laparoscopic colorectal procedure was right colectomy (41.2%). The lowest rate of conversion is seen with right colectomy while proctectomy had the highest rate of conversion (31.2% vs. 12.9%, AOR, 2.81, P < .01). Postsurgical complications including intra-abdominal abscess (AOR, 2.64), prolonged ileus (AOR, 1.50), and wound infection (AOR, 2.38) were higher in procedures requiring conversion (P < .01).

Conclusions:

Conversion of laparoscopic to open colorectal resection occurs in 14.3% of cases. Compared with patients who had laparoscopic operations, patients who had conversion to open surgery had a higher mortality, higher overall morbidity, longer length of hospitalization, and increased hospital charges. The lowest conversion rate was in right colectomy and the highest was in proctectomy procedures. Wound infection in converted procedures is higher than in laparoscopic and open procedures.

National Trends in the Use of Inpatient Hospitalization for Combined Abdominoplasty and Breast Surgery

BACKGROUND

Combined procedures involving elective breast surgery at the time of abdominoplasty are frequently performed procedures in aesthetic plastic surgery. While found to be safe outpatient procedures, many surgeons elect to perform combined abdominoplasty/breast surgery as inpatient surgery. This study was performed to explore the practice of performing the combined procedure as an inpatient in the United States.

METHODS

The Nationwide Inpatient Sample database was evaluated using ICD-9CM procedural codes to identify hospitalizations where patients underwent abdominoplasty combined with breast surgery. We trended the frequency of this combined procedure, and evaluated the rate of acute post-operative complications, length of inpatient hospitalization, and total hospital charges.

RESULTS

Between 2004 and 2011, 29,235 combined abdominoplasty/breast procedures were performed as inpatient in United States. The rate of major post-operative complications in the acute hospitalization period was 1.12% and included CVA (0.02%), respiratory failure (0.6%), pneumonia (0.3%), VTE (0.1%), and myocardial infarction (0.1%). Hospitalization averaged 1.8 days and resulted in $31,177 of hospital charges. The demographics of the combined procedure transitioned as i) frequency of inpatient surgeries decreased, ii) percent of patients >50 yr increased, and iii) hospital charges increased from 2004 to 2011.

CONCLUSION

A significant number of surgeons are performing combined abdominoplasty and elective breast surgery as inpatient procedures in United States. The combined surgery is safe but is associated with small risk of major post-operative complications. A short inpatient hospitalization may be beneficial for high-risk patients interested in combined procedures, but must be analyzed against the rising costs of inpatient surgery.

Does immediate tissue expander placement increase immediate postoperative complications in patients with breast cancer?

The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P < 0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P < 0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.

Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004-2011

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

Laparoscopic Appendectomy Trends and Outcomes in the United States: Data from the Nationwide Inpatient Sample (NIS), 2004–2011

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

Patient characteristics and comorbidities associated with cerebrovascular accident following acute myocardial infarction in the United States

BACKGROUND

Although cerebrovascular accident (CVA) is a relatively infrequent complication of acute myocardial infarction (AMI), the occurrence of CVA in patients with AMI is associated with increased morbidity and mortality. We wanted to assess post-AMI CVA rate in the United States and identify the associated patient characteristics, comorbidities, type of AMI, and utilization of invasive procedures.

METHODS

This is an observational study from the Nationwide Inpatient Sample, 2006-2008. Using multivariate regression models, we assessed predictive risk factors for post-AMI CVA among patients admitted for AMI.

RESULTS

Among the 1,924,413 patients admitted for AMI, the overall rate of CVA was 2% (ischemic stroke: 1.47%, transient ischemic attack [TIA]: 0.35% and hemorrhagic stroke: 0.21%). In this sample of AMI patient, higher incidence of CVA was associated with: CHF (adjusted odds ratio [AOR] 1.71; 95% confidence interval [CI], 1.58-1.84,), age over 65 AOR, 1.65; 95% CI, 1.60-1.70, alcohol abuse AOR, 1.60; 95% CI, 1.49-1.73, cocaine use AOR, 1.48; 95% CI, 1.29-1.70, atrial fibrillation AOR, 1.43; 95% CI, 1.39-1.46, Black race AOR, 1.35; 95% CI, 1.30-1.40, female gender AOR, 1.32; 95% CI, 1.29-1.35, peripheral vascular disease [PVD] AOR, 1.26; 95% CI, 1.22-1.30, coronary artery bypass graft (CABG) AOR, 1.22; 95% CI, 1.17-1.27, P<0.0001, STEMI AOR, 1.17; 95% CI, 1.14-1.20 and teaching hospitals AOR, 1.09; 95% CI, 1.06-1.12.

CONCLUSION

Female gender, older age (age≥65), black ethnicity, comorbidities including CHF, PVD, atrial fibrillation as well as STEMI and undergoing CABG were associated with the highest risk of CVA post-AMI.

Predictive risk factors of early postoperative enteric fistula in colon and rectal surgery

Early postoperative enteric fistula (PEF) is a complication associated with a high rate of morbidity and mortality in colon and rectal surgery. We evaluated the effect of patient characteristics, comorbidities, pathology, resection type, surgical technique, lysis of adhesions, and admission type on the rate of PEF in colorectal surgery. Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. A total of 646,414 patients underwent colorectal resection during this period. Overall, the rate of PEF was 0.37 per cent (2407 patients). Using multivariate regression analysis, Crohn's disease (adjusted odds ratio [AOR], 4.68), lysis of abdominal adhesions (AOR, 4.25), open procedure (AOR, 3.18), and transverse colectomy (AOR, 2.13) significantly impacted the risk of PEF. Although teaching hospitals (AOR, 1.69), obesity (AOR, 1.40), male gender (AOR, 1.30), emergent surgery (AOR, 1.27), age older than 65 years (AOR, 1.24), and diabetes mellitus (AOR, 1.21) also had statistically significant impact on rates of PEF, these were less clinically significant than the other factors. The presence of Crohn's disease and lysis of abdominal adhesions are strongly associated with the development of PEF after colorectal surgery. Laparoscopic surgery was associated with a lower rate of PEF; further studies would be needed to evaluate the importance of this finding.

Predictive factors of acute renal failure in colon and rectal surgery

Postoperative acute renal failure (ARF) is a major factor of morbidity and mortality in colon and rectal surgery. The objectives of this study were: 1) to determine the frequency of ARF in colorectal surgery; and 2) to evaluate the impact of patient characteristics, comorbidities, resection type, pathology, surgical technique, and admission type on ARF. Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2006 to 2008. A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of ARF was 7.41 per cent (elective surgery: 3.38% vs emergent surgery: 12.99% ; P<0.01). Using multivariate regression analysis, chronic renal failure (adjusted odds ratio [AOR], 5.37), emergent operation (AOR, 2.64), total colectomy (AOR, 2.61), age 65 years or older (AOR, 2.02), liver disease (AOR, 1.82), congestive heart failure (AOR, 1.81), alcohol abuse (AOR, 1.67), peripheral vascular disease (AOR, 1.50), obesity (AOR, 1.45), malignant tumor (AOR, 1.44), open operation (AOR, 1.37), male sex (AOR, 1.37), left colectomy (AOR, 1.32), black race (AOR, 1.22), and teaching hospital (AOR, 1.05) were associated with higher risk of ARF. There was no association between hypertension, diabetes, chronic lung disease, smoking, transverse colectomy, proctectomy, diverticulitis, ulcerative colitis, or Crohn's disease and ARF. Chronic renal failure, emergent operation, total colectomy and age 65 years or older are potent independent predictors of ARF. In high-risk circumstances, specific care should be taken to prevent renal insults.

Overview of outcomes of laparoscopic and open Roux-en-Y gastric bypass in the United States

INTRODUCTION

Roux-en-Y Gastric Bypass is the gold standard procedure for weight loss surgery and is the most commonly performed bariatric operation in the United States. Laparoscopic gastric bypass (LGBP) has become the predominantly used technique for weight loss surgery since 2004. The aim of this study was to compare surgical outcomes of LGBP versus open gastric bypass (OGBP) for the treatment of morbid obesity.

METHODS

Using the Nationwide Inpatient Sample database, clinical data of morbidly obese patients who underwent LGBP or OGBP from 2006 to 2008 were analyzed. Outcome measures included patient characteristics, comorbidities, postoperative complications, length of hospital stay (LOS), hospital charges, and in-hospital mortality.

RESULTS

A total of 226,043 morbidly obese patients underwent gastric bypass during the three-year period (LGBP: 183,452 [81.16%], OGBP: 42,591[18.84%]). The majority of patients in both groups were female (LGBP: 81.0% vs. OGBP: 78.5%, p < 0.01) and Caucasian (LGBP: 73.9% vs. OGBP: 72.6%, p < 0.01). Most comorbidities were significantly higher in the OGBP group. All specific postoperative complications were significantly higher in the OGBP group (urinary tract infection [UTI], pneumonia, acute renal failure, respiratory failure, myocardial infarction, venous thromboembolism, ileus, gastrointestinal leak, wound infection, and bowel obstruction). LGBP was associated with lower overall postoperative complications (3.5% vs. 10.8%; p < 0.01), shorter LOS (2.4 days vs. 4.2 days; p < 0.01), lower mortality (0.06 vs. 0.52; p < 0.01), and lower hospital costs ($39,570 vs. $45,629; p < 0.01) compared with the OGBP.

CONCLUSION

LGBP was associated with shorter LOS, lower morbidity, lower mortality, and lower hospital costs compared with those of OGBP. The laparoscopic approach to gastric bypass should be considered the gold standard approach for the treatment of morbid obesity.

Does primary anastomosis with diversion have any advantages over Hartmann's procedure in acute diverticulitis?

BACKGROUND

The optimal treatment for acute complicated diverticulitis is still a matter of debate. We evaluated outcomes of primary anastomosis with proximal diversion (PAD) versus Hartman's procedure (HP) in acute diverticulitis.

METHODS

Using the National Inpatient Sample database, we examined the clinical data of patients who underwent an urgent open colorectal resection (sigmoidectomy or anterior resection) for acute diverticulitis from 2002 to 2007 in the United States. We evaluated patient characteristics, patient comorbidities, perioperative complications, in-hospital mortality, length of hospital stay and total hospital charges between two groups.

RESULTS

A total of 99,259 patients underwent urgent surgery for acute diverticulitis during these years (Primary anastomosis without diversion: 39.3%; HP: 57.3% and PAD: 3.4%). The overall complication rate was lower in the PAD group compared with the HP group (PAD: 39.06% vs. HP: 40.84%; p = 0.04). Patients in the HP group had a shorter mean length of stay (12.5 vs.14.4 days, p < 0.001) and lower mean hospital costs (USD 65,037 vs. USD 73,440, p < 0.01) compared with the PAD group. Mortality was higher in the HP group (4.82 vs. 3.99%, p = 0.03).

CONCLUSION

PAD has improved outcomes compared with HP, and should be considered in patients who are deemed candidates for two-stage operations for acute diverticulitis.

Predictive factors of acute respiratory failure in esophagectomy for esophageal malignancy

Acute respiratory failure (ARespF) is a common complication after esophagectomy that contributes to higher morbidity and mortality. Using the Nationwide Inpatient Sample database, we sought to identify predictors of ARespF in 6352 patients who underwent esophagectomy for malignancy between 2006 and 2008. Multivariate regression analyses were performed to identify preoperative factors (patient characteristics, comorbidities, procedural type, tumor's location, hospital teaching status, and payer type) predictive of ARespF in esophagectomy. The overall rate of ARespF was 27.08 per cent. For comorbidities, independent risk factors for higher rate of ARF included weight loss (adjusted odds ratio [AOR], 3.63; 95% confidence interval [CI], 3.02 to 4.37), pulmonary hypertension (AOR, 2.38; 95% CI, 1.85 to 3.45), congestive heart failure (AOR, 2.35; 95% CI, 1.77 to 3.13), liver disease (AOR, 1.95; 95% CI, 1.22 to 3.12), chronic lung disease (AOR, 1.40; 95% CI, 1.17 to 1.66), and anemia (AOR, 1.26; 95% CI, 1.04 to 1.51). Cervical location of malignancy (AOR, 2.32; 95% CI, 1.51 to 3.56), total esophagectomy (AOR, 1.64; 95% CI, 1.41 to 1.90), and nonteaching hospital (AOR, 1.45; 95% CI, 1.20 to 1.75) were independent risk factors for ARespF. There was no effect of age, gender, race, hypertension, diabetes, renal failure, obesity, smoking, peripheral vascular disorder, or payer type on ARespF. We identified multiple preoperative risk factors that have an impact on development of ARespF after esophagectomy. Surgeons can use these factors to inform patients of potential risks and should consider these factors during surgical-decision making.

Predictive factors of in-hospital mortality in colon and rectal surgery

BACKGROUND

Knowledge of the independent risk factors for mortality in colon and rectal surgery can aid surgeons in surgical decision making and in providing patients with appropriate information about the risks of surgery. This study endeavors to identify the risk factors for mortality that are associated with colon and rectal surgery.

STUDY DESIGN

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2006 to 2008. Multivariate regression analysis was performed to identify factors predictive of in-hospital mortality.

RESULTS

A total of 975,825 patients underwent colon and rectal resection during this period. Overall, the rate of in-hospital mortality was 4.50% (elective surgery, 1.42% vs emergent surgery, 8.76%; p < 0.01). Mortality was lower after laparoscopic compared with open operation (1.43% vs 4.74%; p < 0.01). Using multivariate regression analysis, significant risk factors for in-hospital mortality were emergent surgery (adjusted odds ratio [AOR] = 3.53), liver disease (AOR = 3.02), age older than 65 years (AOR = 2.92), total colectomy (AOR = 2.88), chronic renal failure (AOR = 2.37), malignant tumor (AOR = 2.0), open operation (AOR = 1.85), peripheral vascular disease (AOR = 1.81), diverticulitis (AOR = 1.77), transverse colectomy (AOR = 1.43), chronic lung disease (AOR = 1.41), ulcerative colitis (AOR = 1.40), left colectomy (AOR = 1.31), alcohol abuse (AOR = 1.21), male sex (AOR = 1.12), nonteaching hospital (AOR = 1.11), and African-American race (AOR = 1.09). There was no association between hypertension, diabetes, congestive heart failure, obesity, smoking, proctectomy, sigmoidectomy, or Crohn disease and in-hospital mortality.

CONCLUSIONS

In patients undergoing colorectal surgery, emergent surgery, liver disease, total colectomy, age older than 65 years, chronic renal failure, and malignant tumor are the major risk factors for in-hospital mortality.

Predictive factors of early bowel obstruction in colon and rectal surgery: data from the Nationwide Inpatient Sample, 2006-2008

BACKGROUND

Early postoperative bowel obstruction is associated with considerable morbidity and mortality after colorectal surgery. We evaluated the impact of patient characteristics, patient comorbidities, pathology, resection site, surgical technique, admission type, and teaching hospital status on the incidence of in-hospital bowel obstruction after colorectal surgery.

STUDY DESIGN

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colorectal resection from 2006 to 2008. Regression analyses were performed to identify factors predictive of in-hospital bowel obstruction.

RESULTS

A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of postoperative bowel obstruction was 8.65% (elective surgery: 5.32% vs emergent surgery: 13.26%; p < 0.01). Bowel obstruction was less frequent after laparoscopic procedures compared with open procedures (6.61% vs 8.81%; p < 0.01). Using multivariate regression analysis, Crohn disease (adjusted odds ratio [AOR] = 12.32), emergent surgery (AOR = 2.54), malignant tumor (AOR = 1.84), diverticulitis (AOR = 1.45), age older than 65 years (AOR = 1.22), female sex (AOR = 1.14), history of alcohol abuse (AOR = 1.12), transverse colectomy (AOR = 1.11), peripheral vascular disease (AOR = 1.07), left colectomy (AOR = 1.06), chronic lung disease (AOR = 1.05), open procedure (AOR = 1.05), African-American race (AOR = 1.03), and teaching hospital (AOR = 1.02) were associated with a higher risk of in-hospital bowel obstruction. There was no association between hypertension, diabetes, congestive heart failure, chronic renal failure, liver disease, obesity, smoking, proctectomy or total colectomy, and early bowel obstruction.

CONCLUSIONS

Early bowel obstruction is a relatively common complication after colorectal surgery. Crohn disease patients had a 12-fold higher incidence of early bowel obstruction, and emergent surgery and malignancy were relevant predictors of early bowel obstruction.

Outcomes of laparoscopic versus open colectomy in elective surgery for diverticulitis

BACKGROUND

The role of laparoscopy in the management of diverticular disease is evolving. Concerns were raised in the past because laparoscopic resection for diverticulitis is often difficult and occasionally hazardous. This study was undertaken to evaluate the difference in overall outcomes between elective open and laparoscopic surgery with or without anastomosis for diverticulitis.

METHODS

Using the National Inpatient Sample (NIS) database, clinical data of patients who underwent elective open and laparoscopic surgery (lap) for diverticulitis from 2002 to 2007 were collected and analyzed. Patients who underwent emergent surgery were excluded.

RESULTS

A total of 124,734 patients underwent elective surgery for diverticulitis: open, 110,172 (88.3%); lap, 14,562 (11.7%). The overall intraoperative complication rate was significantly lower in the laparoscopy group (0.63% vs. 1.15%, P < 0.01). However, there was no significant difference observed in ureteral injury between groups (open, 0.17%; lap, 0.12%, P = 0.15). All evaluated postoperative complications (ileus, abdominal abscess, leak, wound infection, bowel obstruction, urinary tract infection, pneumonia, respiratory failure, venous thromboembolism) were significantly higher for the open procedures. The laparoscopy group had a shorter mean hospital stay (lap, 5.06 days; open, 6.68 days, P < 0.01) and lower total hospital charges (lap, $36,389; open, $39,406, P < 0.01) than the open group. Also, mortality was four times higher in the open group (open, 0.54%; lap, 0.13%, P < 0.01).

CONCLUSIONS

The laparoscopic operation was associated with lower morbidity, lower mortality, shorter hospital stay, and lower hospital charges compared to the open operation for diverticulitis. Elective laparoscopic surgery for diverticulitis is safe and can be considered the preferred operative option.

Predictive factors of splenic injury in colorectal surgery: data from the Nationwide Inpatient Sample, 2006-2008

OBJECTIVES

To determine frequency of splenic injury and to evaluate predictive risk factors of splenic injury during colorectal surgery.

DESIGN

Retrospective database analysis.

SETTING

The National Inpatient Sample database.

PATIENTS

Patients who underwent a colorectal resection during the period from 2006 to 2008 in the United States.

MAIN OUTCOME MEASURES

Patient characteristics, patient comorbidities, type of pathology, type of resection, surgical technique used, type of admission, and teaching hospital status were evaluated for splenic injury during colorectal surgery.

RESULTS

A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of splenic injury was 0.96%, of which 84.75% were treated with complete splenectomy (splenorrhaphy, 13.55%; partial splenectomy, 1.70%). The most common procedure associated with splenic injury was transverse colectomy (3.40%). Using multivariate regression analysis, we found that transverse colectomy (adjusted odds ratio [AOR], 5.30), left colectomy (AOR, 5.08), total colectomy (AOR, 2.85), open operation (AOR, 2.68), malignant tumor (AOR, 2.11), diverticulitis (AOR, 1.93), teaching hospital (AOR, 1.73), male sex (AOR 1.20), peripheral vascular disease (AOR, 1.14), and emergent admission (AOR, 1.06) were associated with a higher risk of splenic injury. There was no association between age, race, hypertension, diabetes, chronic lung disease, congestive heart failure, renal failure, liver disease, obesity, sigmoidectomy, proctectomy, ulcerative colitis, or Crohn disease and splenic injury.

CONCLUSIONS

Type of resection (transverse, total, or left colectomy), type of pathology (malignancy or diverticulitis), open operation, and teaching hospital are potent independent predictors of splenic injury. Male sex, peripheral vascular disease, and emergent admission are less effective predictors. Surgeons should be aware of these risk factors and inform patients accordingly. In higher-risk circumstances, it may be appropriate to consider prophylactic vaccination.

Comparison of outcomes of laparoscopic versus open appendectomy in adults: data from the Nationwide Inpatient Sample (NIS), 2006-2008

INTRODUCTION

Although laparoscopic appendectomy (LA) is being performed with increased frequency, the utilization of laparoscopy in the management of acute appendicitis remains controversial, and it continues to be used selectively.

OBJECTIVES

This study aims to evaluate outcomes of LA vs. open appendectomy (OA) in perforated and non-perforated appendicitis in adults.

METHODS

Using the Nationwide Inpatient Sample database, clinical data of adults who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008. Incidental and elective appendectomies were excluded.

RESULTS

A total of 573,244 adults underwent urgent appendectomy during these 3 years. Overall, 65.2% of all appendectomies were performed laparoscopically. Utilization of LA increased 23.7% from 58.2% in 2006 to 72.0% in 2008. In acute non-perforated appendicitis, LA had a lower overall complication rate (4.13% vs. 6.39%, p < 0.01), lower in-hospital mortality (0.03% vs. 0.05%, p < 0.01), and shorter mean length of hospital stay (LOS; 1.7 vs. 2.4 days, p < 0.01) compared with OA; however, hospital charges were higher in the LA group ($22,948 vs. $20,944, p < 0.01). Similarly, in perforated appendicitis, LA was associated with a lower overall complication rate (18.75% vs. 26.76%, p < 0.01), lower in-hospital mortality (0.06% vs. 0.31%, p < 0.01), lower mean hospital charges ($32,487 vs. $38,503, p < 0.01), and shorter mean LOS (4.0 vs. 6.0 days, p < 0.01) compared with OA.

CONCLUSION

LA is safe and associated with lower morbidity, lower mortality, and shorter hospital stay with acute perforated and non-perforated appendicitis. Also, in perforated cases, LA had an advantage over OA in hospital charges. LA should be considered the procedure of choice for perforated and non-perforated appendicitis in adults.

Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass

HYPOTHESIS

Patient characteristics and comorbidities, payer type, and operative technique (laparoscopic vs open) predict the risk of gastrointestinal (GI) tract leak in patients with morbid obesity undergoing gastric bypass.

DESIGN

Retrospective database analysis.

SETTING

Nationwide Inpatient Sample.

PATIENTS

Between January 1, 2006, and December 31, 2008, patients who underwent open or laparoscopic gastric bypass to treat morbid obesity.

MAIN OUTCOME MEASURES

Factors predictive of GI tract leak using multivariate regression analyses.

RESULTS

A total 226,452 patients underwent laparoscopic (81.2%) or open (18.8%) gastric bypass during the 3-year period. Most patients were female (80.5%) and of white race/ethnicity (73.6%). The mean age of patients was 43.6 years; 30.0% of patients were older than 50 years. The overall prevalence of in-hospital GI tract leak was 0.7%. The GI tract leak rate was significantly lower in laparoscopic compared with open gastric bypass (0.3% vs 2.0%, P < .01). Using multivariate regression analysis, factors associated with higher risk of GI tract leak were open gastric bypass (adjusted odds ratio [aOR], 4.85), congestive heart failure (aOR, 3.04), chronic renal failure (aOR, 2.38), age older than 50 years (aOR, 1.82), Medicare payer (aOR, 1.54), male sex (aOR, 1.50), and chronic lung disease (aOR, 1.21). The GI tract leak rate was unaffected by race/ethnicity, hypertension, diabetes mellitus, sleep apnea, hyperlipidemia, liver disease, peripheral vascular disease, or smoking.

CONCLUSIONS

We identified multiple factors associated with the higher risk of GI tract leak after gastric bypass. Surgeons should use this knowledge to counsel patients and possibly alter operative plans in high-risk patients to minimize this risk.

Increasing utilization of laparoscopic gastric banding in the adolescent: data from academic medical centers, 2002-2009

Bariatric surgery in the adolescent continues to be a controversial topic. This study compared the utilization and perioperative outcomes of adolescent bariatric surgery performed at academic centers from 2002 to 2006 versus 2007 to 2009. We obtained data from the University HealthSystem Consortium for all adolescent patients (ages 12-18 years) who underwent bariatric surgery for the treatment of morbid obesity between 2002 and 2009. Outcomes including type of procedure, characteristics, length of stay, 30-day readmission, morbidity, and in-hospital mortality were compared between the two time periods. From 2007 to 2009, 340 adolescents underwent bariatric surgery at 63 academic hospitals. The mean number of adolescent bariatric procedures performed/year increased from 61.8 in 2002 to 2006 to 113.3 procedures/year in 2007 to 2009. There was an increase in utilization of laparoscopic gastric banding from 29 per cent to 50 per cent with a decrease in utilization of gastric bypass from 62 per cent to 48 per cent, respectively. For 2007 to 2009, the overall morbidity was 2.9 per cent with a 30-day readmission of 1.5 per cent and an in-hospital mortality of 0 per cent. Within the context of academic medical centers, adolescent bariatric surgery is associated with low morbidity and no mortality. Compared with 2002 to 2006, there has been an increase in the number of adolescent bariatric operations with increase in utilization of the laparoscopic gastric banding.

Outcomes of right vs. left colectomy for colon cancer

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increasing Utilization of Laparoscopic Gastric Banding in the Adolescent: Data from Academic Medical Centers, 2002-2009

Bariatric surgery in the adolescent continues to be a controversial topic. This study compared the utilization and perioperative outcomes of adolescent bariatric surgery performed at academic centers from 2002 to 2006 versus 2007 to 2009. We obtained data from the University HealthSystem Consortium for all adolescent patients (ages 12-18 years) who underwent bariatric surgery for the treatment of morbid obesity between 2002 and 2009. Outcomes including type of procedure, characteristics, length of stay, 30-day readmission, morbidity, and in-hospital mortality were compared between the two time periods. From 2007 to 2009, 340 adolescents underwent bariatric surgery at 63 academic hospitals. The mean number of adolescent bariatric procedures performed/year increased from 61.8 in 2002 to 2006 to 113.3 procedures/year in 2007 to 2009. There was an increase in utilization of laparoscopic gastric banding from 29 per cent to 50 per cent with a decrease in utilization of gastric bypass from 62 per cent to 48 per cent, respectively. For 2007 to 2009, the overall morbidity was 2.9 per cent with a 30-day readmission of 1.5 per cent and an in-hospital mortality of 0 per cent. Within the context of academic medical centers, adolescent bariatric surgery is associated with low morbidity and no mortality. Compared with 2002 to 2006, there has been an increase in the number of adolescent bariatric operations with increase in utilization of the laparoscopic gastric banding.

Factors Predictive of Venous Thromboembolism in Bariatric Surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.

Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair

The optimal operative approach for repair of diaphragmatic hernia remains debated. The aim of this study was to examine the utilization of laparoscopy and compare the outcomes of laparoscopic versus open paraesophageal hernia repair performed at academic centers. Data was obtained from the University HealthSystem Consortium database on 2726 patients who underwent a laparoscopic (n = 2069) or open (n = 657) paraesophageal hernia repair between 2007 and 2010. The data were reviewed for demographics, length of stay, 30-day readmission, morbidity, in-hospital mortality, and costs. For elective procedures, utilization of laparoscopic repair was 81 per cent and was associated with a shorter hospital stay (3.7 vs 8.3 days, P < 0.01), less requirement for intensive care unit care (13% vs 35%, P < 0.01), and lower overall complications (2.7% vs 8.4%, P < 0.01), 30-day readmissions (1.4% vs 3.4%, P < 0.01) and costs ($15,227 vs $24,263, P < 0.01). The in-hospital mortality was 0.4 per cent for laparoscopic repair versus 0.0 per cent for open repair. In patients presenting with obstruction or gangrene, utilization of laparoscopic repair was 57 per cent and was similarly associated with improved outcomes compared with open repair. Within the context of academic centers, the current practice of paraesophageal hernia repair is mostly laparoscopy. Compared with open repair, laparoscopic repair was associated with superior perioperative outcomes even in cases presenting with obstruction or gangrene.

Factors predictive of venous thromboembolism in bariatric surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.

Utilization of Laparoscopy in Colorectal Surgery for Cancer at Academic Medical Centers: Does Site of Surgery Affect Rate of Laparoscopy?

Use of laparoscopy in colorectal cancer surgery is still limited. The aim of this study was to determine the rate of use of laparoscopic colorectal surgery for cancer at academic medical centers and to evaluate if the site of surgery influences the rate of use. Clinical data of patients who underwent laparoscopic or open colon and rectal resections for cancer from 2007 to 2009 were obtained from the University HealthSystem Consortium database. Data concerning rate of laparoscopy, length of stay, morbidity, and risk-adjusted mortality were obtained. During the 36-month study period, 22,780 operations were performed. The overall rate for use of laparoscopy was 14.8 per cent. Laparoscopy was most often used for total colectomy (22.6%), sigmoid colectomy (17.3%), cecectomy (17.1%), and right hemicolectomy (17.0%). Laparoscopy was most infrequently used for abdominoperineal resection (8.0%), transverse colectomy (10.0%), and left hemicolectomy (13.1%). Length of stay for laparoscopic colon and rectal procedures was 3.2 days shorter than for open surgery. Although the benefits of laparoscopic colorectal surgery for cancer have been demonstrated, the use of laparoscopy for colorectal resection remains under 20 per cent for colon cancer and under 10 per cent for rectal cancer. Further studies are needed to determine the factors limiting the use of laparoscopy in colorectal surgery.

Outcomes of laparoscopic and open appendectomy for acute appendicitis in patients with acquired immunodeficiency syndrome

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.

Outcomes of Laparoscopic and Open Appendectomy for Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.

Utilization and Outcomes of Laparoscopic Versus Open Paraesophageal Hernia Repair

The optimal operative approach for repair of diaphragmatic hernia remains debated. The aim of this study was to examine the utilization of laparoscopy and compare the outcomes of laparoscopic versus open paraesophageal hernia repair performed at academic centers. Data was obtained from the University HealthSystem Consortium database on 2726 patients who underwent a laparoscopic (n = 2069) or open (n = 657) paraesophageal hernia repair between 2007 and 2010. The data were reviewed for demographics, length of stay, 30-day readmission, morbidity, in-hospital mortality, and costs. For elective procedures, utilization of laparoscopic repair was 81 per cent and was associated with a shorter hospital stay (3.7 vs 8.3 days, P < 0.01), less requirement for intensive care unit care (13% vs 35%, P < 0.01), and lower overall complications (2.7% vs 8.4%, P < 0.01), 30-day readmissions (1.4% vs 3.4%, P < 0.01) and costs ($15,227 vs $24,263, P < 0.01). The in-hospital mortality was 0.4 per cent for laparoscopic repair versus 0.0 per cent for open repair. In patients presenting with obstruction or gangrene, utilization of laparoscopic repair was 57 per cent and was similarly associated with improved outcomes compared with open repair. Within the context of academic centers, the current practice of paraesophageal hernia repair is mostly laparoscopy. Compared with open repair, laparoscopic repair was associated with superior perioperative outcomes even in cases presenting with obstruction or gangrene.

Utilization of laparoscopy in colorectal surgery for cancer at academic medical centers: does site of surgery affect rate of laparoscopy?

Use of laparoscopy in colorectal cancer surgery is still limited. The aim of this study was to determine the rate of use of laparoscopic colorectal surgery for cancer at academic medical centers and to evaluate if the site of surgery influences the rate of use. Clinical data of patients who underwent laparoscopic or open colon and rectal resections for cancer from 2007 to 2009 were obtained from the University HealthSystem Consortium database. Data concerning rate of laparoscopy, length of stay, morbidity, and risk-adjusted mortality were obtained. During the 36-month study period, 22,780 operations were performed. The overall rate for use of laparoscopy was 14.8 per cent. Laparoscopy was most often used for total colectomy (22.6%), sigmoid colectomy (17.3%), cecectomy (17.1%), and right hemicolectomy (17.0%). Laparoscopy was most infrequently used for abdominoperineal resection (8.0%), transverse colectomy (10.0%), and left hemicolectomy (13.1%). Length of stay for laparoscopic colon and rectal procedures was 3.2 days shorter than for open surgery. Although the benefits of laparoscopic colorectal surgery for cancer have been demonstrated, the use of laparoscopy for colorectal resection remains under 20 per cent for colon cancer and under 10 per cent for rectal cancer. Further studies are needed to determine the factors limiting the use of laparoscopy in colorectal surgery.

Outcome of laparoscopic adjustable gastric banding and prevalence of band revision and explantation at academic centers: 2007-2009

BACKGROUND

Laparoscopic adjustable gastric banding is gaining in popularity in the United States. Our objective was to examine the outcomes of laparoscopic adjustable gastric banding and the prevalence of band revision and explantation at academic medical centers.

METHODS

Using the "International Classification of Diseases, 9th revision," diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding procedures performed from 2006 to 2009. The outcome measures included demographics, length of hospital stay, perioperative morbidity, mortality, and the prevalence of band revision and explantation.

RESULTS

A total of 10,151 laparoscopic gastric banding procedures were performed from January 2007 to December 2009. The mean length of stay was 1.2 days. The perioperative morbidity rate was 3.0%, and the in-hospital mortality rate was .03%. The prevalence of band revision was .76% and of band explantation was .87%. Compared with the outcome of primary gastric banding, gastric band revision or explantation was associated with a longer length of hospital stay, greater perioperative morbidity, and greater cost.

CONCLUSION

Within the context of the 3-year period of analysis, laparoscopic gastric banding was associated with low perioperative morbidity and mortality and a low prevalence of band revision and explantation.

Predictive factors of mortality in bariatric surgery: data from the Nationwide Inpatient Sample

BACKGROUND

Understanding predictors of mortality in bariatric surgery enables surgeons to use these factors for analysis of risk-adjusted mortality and aids in the surgical decision making and informed consent process.

OBJECTIVES

To evaluate the effect of patient characteristics (age, gender, race, and payer type), preoperative comorbidities, and operative technique (laparoscopic versus open, gastric bypass versus gastric band) on mortality in patients who underwent bariatric operations.

METHODS

Using the National Inpatient Sample database, clinical data of patients with morbid obesity who underwent bariatric surgery from 2006 to 2008 were examined. Multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality.

RESULTS

A total 304,515 patients underwent bariatric surgery over the 3-year period. The majority of patients were female (80%) and Caucasian (74%). Their mean age was 44 years and 31.6% were >50 years old. The most common payer type was private (73.5%). Laparoscopic approach was utilized in 86.2% of cases. The overall in-hospital mortality was 0.12%. Using multivariate regression analysis, male gender (adjusted odds ratio [AOR], 1.7), age >50 years (AOR, 3.8), congestive heart failure (AOR, 9.5), peripheral vascular disease (AOR, 7.4), chronic renal failure (AOR, 2.7), open procedure (AOR, 5.5), and gastric bypass operation (AOR, 1.6) were factors associated with greater mortality. Ethnicity, hypertension, diabetes, liver disease, chronic lung disease, sleep apnea, alcohol abuse, and payer type had no association with mortality in this study.

CONCLUSION

Modifiable risk factors predictive of mortality include open surgery and gastric bypass procedure; nonmodifiable risk factors include older age, male gender, and a history of congestive heart failure, peripheral vascular disease, and chronic renal failure. Surgeons should consider these factors in selection of patients to undergo bariatric operations, providing informed consent, and selection of the procedural type.

Incidence and risk factors of venous thromboembolism in colorectal surgery: does laparoscopy impart an advantage?

OBJECTIVES

Laparoscopy is increasingly used in colon and rectal procedures. However, little is known regarding the incidence of venous thromboembolism (VTE) in laparoscopic colorectal (LC) compared with that in open colorectal (OC) procedures. We aimed to compare the incidences and to highlight the risk factors of developing VTE after LC and OC surgery.

DESIGN

Analysis of the Nationwide Inpatient Sample data from 2002 through 2006.

SETTING

National database.

PATIENTS

Patients who underwent elective LC and OC surgery from 2002 through 2006.

MAIN OUTCOMES MEASURE

Incidence of VTE during initial hospitalization after LC and OC surgery; VTE classified by surgical site, pathology type, and at-risk patient population.

RESULTS

Over a 60-month period, 149,304 patients underwent LC or OC resection. Overall, the incidence of VTE was significantly higher in OC cases (2036 of 141,456 [1.44%]) compared with the incidence in LC cases (65 of 7848 [0.83%]) (P < .001). When stratified according to pathologic condition and surgical site, the overall rate of VTE was highest in patients with inflammatory bowel disease and in those undergoing rectal resections. Patients who underwent OC surgery were almost twice as likely to develop VTE compared with patients who underwent LC surgery. We also identified malignancy, obesity, and congestive heart failure as statistically significant (P < .05) risk factors for VTE in OC and LC surgery.

CONCLUSIONS

On the basis of data from a large clinical data set, the incidence of perioperative VTE is lower after LC than after OC surgery. These findings may help colorectal surgeons use appropriate VTE prophylaxis for patients undergoing colorectal procedures.

Trends in use of bariatric surgery, 2003-2008

BACKGROUND

During the past decade, the field of bariatric surgery has changed dramatically. This study was intended to determine trends in the use of bariatric surgery in the United States. Data used were from the Nationwide Inpatient Sample from 2003 through 2008.

STUDY DESIGN

We used ICD-9 diagnosis and procedural codes to identify all hospitalizations during which a bariatric procedure was performed for the treatment of morbid obesity between 2003 and 2008. Data were reviewed for patient characteristics, annual number of bariatric procedures, and proportion of laparoscopic cases. US Census data were used to calculate the population-based annual rate of bariatric surgery per 100,000 adults. The number of surgeons performing bariatric surgery was estimated by the number of members in the American Society for Metabolic and Bariatric Surgery.

RESULTS

For the period between 2003 and 2008, the number of bariatric operations peaked in 2004 at 135,985 cases and plateaued at 124,838 cases in 2008. The annual rate of bariatric operations peaked at 63.9 procedures per 100,000 adults in 2004 and decreased to 54.2 procedures in 2008. The proportion of laparoscopic bariatric operations increased from 20.1% in 2003 to 90.2% in 2008. The number of bariatric surgeons with membership in the American Society for Metabolic and Bariatric Surgery increased from 931 to 1,819 during the 6 years studied. The in-hospital mortality rate decreased from 0.21% in 2003 to 0.10% in 2008.

CONCLUSIONS

In the United States, the number of bariatric operations peaked in 2004 and plateaued thereafter. Use of the laparoscopic approach to bariatric surgery has increased to >90% of bariatric operations. In-hospital mortality continually decreased throughout the 6-year period.