The Cost of Frailty in Complex Gastrointestinal Surgery.

BACKGROUND: Frailty is a syndrome characterized by decreased physiologic reserve related with aging; it has been associated with increased costs of health care. Factors driving its economic impact remain poorly understood. We examine the association between frailty, complications, and costs in complex gastrointestinal surgery. METHODS: Retrospective review of a prospective database encompassing elective complex gastrointestinal operations from 2017 to 2018 at a tertiary care hospital. Patients were categorized into non-frail (NF): MFI 0, pre-frail (PF): MFI 1-2, and frail (FR): MFI >2 based on the 5-Factor Modified Frailty Index. Linear regression models were applied. RESULTS: 612 patients were included; 268 (44%) were NF, 325 (53%) were PF, and 19 (3%) were FR. The FR group had a longer length of stay (7.26 days) compared to NF (5.05 days) or PF (5.67 days) (p = 0.031). The average total cost of care for all patients was $19,413.06 (CI 18,297.13-20,528.98). The cost for NF was $17,648.54 (CI 15,969.18-19,327.9), PF $20,435.70 (CI 18,911.01-21,960.4, p = .016), and FR patients was $26,809.36 (CI 20,511.9-33,106.81). A complication was observed in 91 patients (14.9%); of these, 76 (12.4%) were serious complications, as defined by NSQIP. There was no difference in incidence of complications (NF 14.93%, PF 14.46%, FR 21.05%, p = .734). On average, a complication added $12,656.67 regardless of frailty category. DISCUSSION: Frail patients are more costly and have a longer length of stay than their more robust counterparts. Complications were the major driver of costs after complex gastrointestinal surgery regardless of frailty status.

Decreasing Colectomy Rates in Advanced Adenomas.

Advanced colon adenomas are commonly treated with colectomy, which is associated with substantial morbidity and mortality. Novel endoscopic resection techniques have been described, including endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESR), which demonstrate promise in treating these neoplasms without colectomy. We performed a retrospective review of patients with advanced adenomas who were referred to a colorectal surgeon for evaluation for resection over 4 years. 40 of 46 (87%) of these patients underwent a successful endoscopic resection. 10 of 46 (21.6%) patients ultimately underwent an operation for a variety of reasons: inability to resect endoscopically (n = 6), invasive cancer on the excised specimen (n = 2), complication of procedure (n = 1), colectomy after polyp recurrence (n = 1). Our study demonstrates EMR and ESD offers an alternative to colectomy in appropriately selected patients with a high success rate. As more surgeons learn advanced endoscopic techniques, there is potential to decrease colectomy rates in benign disease.

Robotic Repair of a Symptomatic Perineal Hernia With Self-Fixating Synthetic Mesh.

Primary acquired perineal hernias are rare defects through the pelvic floor diaphragm. The optimal surgical technique for repair remains unknown, and recurrence rates approach 50%. We present a 65-year-old female without previous obstetric or pelvic surgical history who was found to have herniated sigmoid colon through a 2×2 cm levator ani defect. The patient underwent robotic transabdominal hernia repair with a synthetic self-fixating underlay mesh. The peritoneum was primarily closed and the patient was discharged the same day. There is no sign of recurrence to date. Our minimally invasive approach with extraperitoneal mesh placement provided us with several advantages: ambulatory surgery; excellent visualization of the defect; easier suturing in the deep pelvis compared to traditional laparoscopy; and mesh reinforcement while minimizing the risks of erosion, migration, adhesion, and fistula formation.