A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution.

BACKGROUND: The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. METHODS: Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. RESULTS: There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. CONCLUSIONS: Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.

Remote evaluation of laparoscopic performance using the global operative assessment of laparoscopic skills.

BACKGROUND: Although numerous assessment tools currently exist to evaluate laparoscopic surgical skills, no studies have demonstrated the reliability of such tools when used with telementoring technology. This study aimed to determine the reliability of the Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale for assessing laparoscopic skills remotely and to identify how factors unique to remote assessment such as bandwidth and image quality influence its reliability. METHODS: Four trained observers evaluated 19 participants for their technical performance during a laparoscopic cholecystectomy using the GOALS assessment tool. One observer assessed the study participants directly in the operating room, whereas the three remaining observers were randomly assigned and blinded to a high- (1.5 Mbps), medium- (256 kbps), or low- (64.4 kbps) bandwidth restriction and observed remotely via Skype. The Maryland Visual Comfort Scale was used to evaluate the video quality of the respective connections. RESULTS: The intraclass correlation coefficient (ICC) calculated for the total GOALS score demonstrated a statistically significant correlation of high, medium, and low bandwidths respectively with ICC 0.693 (95 % confidence interval [CI], 0.226-0.883), 0.518 (95 % CI 0.089-0.783), and 0.499 (95 % CI 0.025-0.781). There was a statistically significant difference in the overall perceived visual quality between the high/low (Z = -3.222; P = 0.001) and the medium/low (Z = -3.567; P < 0.001) bandwidth comparison but no difference between the high/medium bandwidths (Z = -0.610; P = 0.542). CONCLUSION: The data suggest that the GOALS assessment tool retains its reliability for intraoperative assessment of laparoscopic skills when used remotely. This is a key requirement in telesimulation programs allowing for structured feedback between the mentor and the mentee. This study quantifies the effect that bandwidth has on the reliability of remote assessment, demonstrating that higher bandwidths improve the utility of these tools.

Perception and Awareness of Bariatric Surgery in Canada: a National Survey of General Surgeons.

BACKGROUND: The objective of this study was to assess Canadian general surgeons' knowledge of bariatric surgery and perceived availability of resources to manage bariatric surgery patients. METHODS: A self-administered questionnaire was developed using a focus group of general surgeons. The questionnaire was distributed at two large general surgery conferences in September and November 2012. The survey was also disseminated via membership association electronic newsletters in November and December 2012. RESULTS: One hundred sixty-seven questionnaires were completed (104 practicing surgeons, 63 general surgery trainees). Twenty respondents were bariatric surgeons. Among 84 non-bariatric surgeons, 68.3 % referred a patient in the last year for bariatric surgery, 79 % agreed that bariatric surgery resulted in sustained weight loss, and 81.7 % would consider referring a family member. Knowledge gaps were identified in estimates of mortality and morbidity associated with bariatric procedures. The majority of surgeons surveyed have encountered patients with complications from bariatric surgery in the last year. Over 50 % of surgeons who do not perform bariatric procedures reported not feeling confident to manage complications, 35.4 % reported having adequate resources and equipment to manage morbidly obese patients, and few are able to transfer patients to a bariatric center. Of the respondents, 73.3 % reported residency training provided inadequate exposure to bariatric surgery, and 85.3 % felt that additional continuing medical education resources would be useful. CONCLUSIONS: There appears to be support for bariatric surgery among Canadian general surgeons participating in this survey. Knowledge gaps identified indicate the need for more education and resources to support general surgeons managing bariatric surgical patients.

Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery.

INTRODUCTION: Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug (NSAID) use after colorectal resection. The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery. METHODS: A retrospective review (2004-2011) was performed on patients who underwent elective colorectal surgery. Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate. RESULTS: A total of 731 patients were identified as having resection with primary anastomosis: 376 (51.4 %) received no NSAIDs and 355 (48.6 %) received ketorolac perioperatively within 5 days after their surgery. There were 24 (3.3 %) leaks, with 12 in both the no NSAIDs (3.2 %) and ketorolac (3.4 %) groups, odds ratio (OR) 1.06 (0.43, 2.62; p = 0.886). Adjusting for smoking, steroid use, and age, there remained no significant difference between ketorolac use and leakage, OR 1.21 (0.52, 2.84; p = 0.660). In our multivariate model, only smoking was a significant predictor of postoperative leak, OR 3.34 (1.30, 8.62; p = 0.021). CONCLUSIONS: There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery. However, further prospective studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended.

Safety of laparoscopic and open approaches for repair of the unilateral primary inguinal hernia: an analysis of short-term outcomes.

BACKGROUND: Primary laparoscopic repair of unilateral inguinal hernias has not achieved widespread recognition mainly because of concerns over safety. METHODS: Prospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program between 2005 and 2010. Complications in patients undergoing unilateral first-time, elective laparoscopic unilateral inguinal hernia repair (LIHR) were compared with open inguinal hernia repair (OIHR). RESULTS: Of 37,645 identified patients, 6,356 (16.9%) underwent LIHR and 31,289 (83.1%) underwent OIHR. Both groups had similar 30-day overall complications, major complications, and mortality rates: 62 (1.0%) vs 307 (1.0%), P = 1.00; 31 (.5%) vs 173 (.5%), P = .57; and 1 (.02%) vs 16 (.05%), P = .34, respectively. Using multivariable logistic regression, overall complications showed no difference, OR 1.01 (95% CI .76 to 1.34; P = .94), as did major complications, OR .90 (95% CI .61 to 1.34; P = .62), although favoring the LIHR group, where OR and CI represent the odss ratio and confidence intervals. CONCLUSION: These data demonstrate no significant difference between elective unilateral LIHR and OIHR with regard to 30-day morbidity and mortality.

Hospital costs associated with laparoscopic and open inguinal herniorrhaphy.

PURPOSE: The purpose of this study was to compare the total hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy. METHODS: A prospectively maintained database was used to identify patients who underwent elective inguinal herniorrhaphy from April 2009 to March 2011. A retrospective review of electronic patient records was performed along with a standardized case-costing analysis using data from the Ontario Case Costing Initiative. The main outcomes were operating room (OR) and total hospital costs. RESULTS: Two hundred eleven patients underwent elective unilateral inguinal herniorrhaphy (117 open and 94 laparoscopic), and 33 patients underwent elective bilateral inguinal herniorrhaphy (9 open and 24 laparoscopic). OR and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach (median total cost, $3207.15 vs $3723.66; P < .001). OR and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total cost, $4574.02 vs $4662.89; P = .827). CONCLUSIONS: In the setting of a Canadian academic hospital, when considering the repair of an elective unilateral inguinal hernia, the OR and total hospital costs of open surgery were significantly lower than for the laparoscopic techniques. There was no statistical difference between OR and total hospital costs when comparing open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopy, further studies incorporating hernia-specific outcomes are necessary to determine the cost-effectiveness of each approach and to define the optimal treatment strategy.

Understanding disposition after referral for bariatric surgery: when and why patients referred do not undergo surgery.

BACKGROUND: Bariatric surgery is an effective long-term solution for weight loss in the severely obese. Prevalence of bariatric surgery has increased over the recent years; however, the attrition rate of those referred who actually undergo surgery is high. The purpose of this study was to examine patients' attrition rates after referral for bariatric surgery at an academic tertiary care institution. When and why patients who were referred for bariatric surgery did not ultimately undergo surgical treatment was examined. METHODS: Charts of 1,237 patients referred to the Toronto Western Hospital Bariatric Program from program inception to February 2011 were retrospectively reviewed. Patient demographics, appointment dates, no shows and cancellations, and when and why patients did not undergo surgery were summarized. RESULTS: Patients' mean age was 47. Most patients were female, and the mean body mass index was 47. Half (50.6 %) of the total persons referred left the program prior to being seen by a health-care professional, and only 36.2 % underwent surgical treatment. Only 2.75 % of persons were ineligible for surgery. A total of 60.6 % of persons self-removed from our program. Reasons for self-removal varied, with the most common reason for leaving the program recorded as "unknown." CONCLUSIONS: Our multidisciplinary program with in-hospital psychosocial resources resulted in very few persons being excluded from receiving surgical treatment. However, less than half of those referred underwent surgery as most persons self-removed from our program for unknown reasons. Further investigation is required to determine which patient, administrative, and system factors play a role in the patients' decision to not undergo bariatric surgical treatment.