Additional procedures performed during elective colon surgery and their adverse impact on postoperative outcomes.

BACKGROUND: The need for additional procedures during a segmental elective colectomy is considered to lead to increased postoperative morbidity, but there have been few data that have validated and quantified this risk. PURPOSE: We hypothesized that patients having additional procedures performed during a segmental colectomy have worse outcomes compared to patients undergoing a colectomy alone. PATIENTS AND METHODS: All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent an elective open or laparoscopic segmental colectomy during 2005-2009 and met the inclusion criteria were analyzed. Using current procedural terminology (CPT) codes, patients were stratified into three groups. Group 1 only had CPT codes for a colectomy. Group 2 had additional CPT codes for procedures that were considered related to the colectomy, such as splenic flexure mobilization and endoscopy or a relatively minor procedure such as an appendectomy. Group 3 included patients that had additional procedures performed along with a segmental colectomy. Serious morbidity, overall morbidity, return to the operating room, and death were calculated and compared for each group. RESULTS: There were 25,996 patients in the open and 20,396 patients in the laparoscopic colectomy group. Thirty-six percent of patients in the open colectomy group vs. 18 % in the laparoscopic colectomy group had additional procedures performed. After adjustment for available differences in the groups, patients undergoing open and laparoscopic segmental colectomy along with an additional procedure had worse postoperative outcomes compared to patients undergoing a colectomy alone. LIMITATIONS: The study is limited by the possibility of coding errors in the ACS NSQIP database leading to a case ascertainment bias and a selection bias given the observational nature of the study. It also could not differentiate between additional procedures that were planned or incidental at the time of surgery. CONCLUSIONS: A proportion of patients undergoing elective open and laparoscopic segmental colon resections undergo additional procedures that adversely impact postoperative outcomes. This is mainly related to the type of additional procedures performed and therefore should be accounted for when counseling patients about the risks of surgery and in comparisons of outcomes.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update.

BACKGROUND: The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system. METHODS: An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated. RESULTS: One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%). CONCLUSION: We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Complications associated with the Nuss procedure: continued evolution of the learning curve.

BACKGROUND: We report unusual and/or significant complications encountered during and after the Nuss Procedure for pectus excavatum. METHODS: This was a retrospective review that was approved by the institutional review board, with parental consent. RESULTS: Seven patients had unique and/or significant complications as follows: (1) laceration of an internal mammary artery during bar placement requiring emergent minithoracotomy; (2) hemopericardium 10 weeks postoperatively after blunt chest trauma requiring exploration of the pericardium and clot evacuation; (3) almost complete recurrence of the pectus excavatum deformity immediately after bar removal; (4 and 5) immediate/early postoperative bar displacement requiring re-operation and placement of 2 bars each; and (6 and 7) almost complete neo-ossification of the Nuss bar, making removal challenging. CONCLUSIONS: The Nuss procedure has met with near-universal acceptance. Complications are just being reported. We describe 7 events to add to the evolving literature as the entire pediatric surgery community participates in the initial learning curve.