Evaluating the Validity of the Clavien-Dindo Classification in Colectomy Studies: A 90-Day Cost of Care Analysis.

BACKGROUND: The Clavien-Dindo classification is widely used to report postoperative morbidity but may underestimate the severity of colectomy complications. OBJECTIVE: The purpose of this study was to assess how well the Clavien-Dindo classification represents the severity of all grades of complications after colectomy using cost of care modeling. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a comprehensive cancer center. PATIENTS: Consecutive patients (N = 1807) undergoing elective colon or rectal resections without a stoma performed at Memorial Sloan Kettering Cancer Center between 2009 and 2014 who were followed up for ≥90 days, were not transferred to other hospitals, and did not receive intraperitoneal chemotherapy were included in the study. MAIN OUTCOME MEASURES: Complication severity was measured by the highest-grade complication per patient and attributable outpatient and inpatient costs. Associations were evaluated between patient complication grade and cost during 3 time periods: the 90 days after surgery, index admission, and postdischarge (<90 d). RESULTS: Of the 1807 patients (median age = 62 y), 779 (43%) had a complication; 80% of these patients had only grade 1 or 2 complications. Increasing patient complication grade correlated with 90-day cost, driven by inpatient cost differences (p < 0.001). For grade 1 and 2 patients, most costs were incurred after discharge and were the same between these grade categories. Among patients with a single complication (52%), there was no difference in index hospitalization, postdischarge, or total 90-day costs between grade 1 and 2 categories. LIMITATIONS: The study was limited by its retrospective design and generalizability. CONCLUSIONS: The Clavien-Dindo classification correlates well with 90-day costs, driven largely by inpatient resource use. Clavien-Dindo does not discriminate well among patients with low-grade complications in terms of their substantial postdischarge costs. These patients represent 80% of patients with a complication after colectomy. Examining the long-term burden associated with complications can help refine the Clavien-Dindo classification for use in colectomy studies. See Video Abstract at http://links.lww.com/DCR/B521. EVALUACIN DE LA VALIDEZ DE LA CLASIFICACIN DE CLAVIENDINDO EN ESTUDIOS DE COLECTOMA ANLISIS DEL COSTO DE LA ATENCIN EN DAS: ANTECEDENTES:La clasificación de Clavien-Dindo es utilizada ampliamante para conocer la morbilidad posoperatoria, pero puede subestimar la gravedad de las complicaciones de la colectomía.OBJETIVO:Evaluar que tan bien representa la clasificación de Clavien-Dindo la gravedad de todos los grados de complicaciones después de la colectomía utilizando un modelo de costo de la atención.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Centro oncológico integral.PACIENTES:Pacientes consecutivos (n = 1807) sometidos a resecciones electivas de colon o recto sin estoma realizadas en el Memorial Sloan Kettering Cancer Center entre 2009 y 2014 que fueron seguidos durante ≥ 90 días, no fueron transferidos a otros hospitales y no recibieron quimioterapia intraperitoneal.PRINCIPALES MEDIDAS DE VALORACION:Gravedad de la complicación medida por la complicación de mayor grado por paciente y los costos atribuibles para pacientes ambulatorios y hospitalizados. Se evaluó la asociación entre el grado de complicación del paciente y el costo durante 3 períodos de tiempo: posterior a la cirugía (hasta 90 días), a su ingreso y posterior al egreso (hasta 90 días).RESULTADOS:De los 1807 pacientes (mediana de edad de 62 años), 779 (43%) tuvieron una complicación; El 80% de estos pacientes tuvieron solo complicaciones de grado 1 o 2. El aumento del grado de complicación del paciente se correlacionó con el costo a 90 días, impulsado por las diferencias en el costo de los pacientes hospitalizados (p <0,001). Para los pacientes de grado 1 y 2, la mayoría de los costos se incurrieron después del alta y fueron los mismos entre ambas categorías. Entre los pacientes con una sola complicación (52%), no hubo diferencia en el índice de hospitalización, posterior al alta o en el costo total de 90 días entre las categorías de grado 1 y 2.LIMITACIONES:Diseño retrospectivo, generalizabilidad.CONCLUSIONES:La clasificación de Clavien-Dindo se correlaciona bien con los costos a 90 días, impulsados en gran parte por la utilización de recursos de pacientes hospitalizados. Clavien-Dindo no discrimina entre los pacientes con complicaciones de bajo grado en términos de sus costos sustanciales posterior al alta. Estos pacientes representan el 80% de los pacientes aquellos con una complicación tras la colectomía. Examinar la carga a largo plazo asociada a las complicaciones puede ayudar a mejorar la clasificación de Clavien-Dindo para su uso en estudios de colectomía. Consulte Video Resumen en http://links.lww.com/DCR/B521.

Intracorporeal Anastomoses in Minimally Invasive Right Colectomies Are Associated With Fewer Incisional Hernias and Shorter Length of Stay.

BACKGROUND: Intracorporeal anastomosis is associated with several short-term benefits. However, it is a technically challenging procedure with potential risk OBJECTIVE:: The purpose of this study was to investigate differences in short-term complications and long-term incisional hernia rates after robotic right colectomy with intracorporeal versus extracorporeal anastomoses and standardized extraction sites. DESIGN: This was a historical cohort study. SETTINGS: The study was conducted at a single institution. PATIENTS: All of the patients undergoing robotic right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site or extracorporeal anastomosis with a vertical midline extraction site from 2013 to 2017 were eligible. Exclusion criteria were conversion to laparotomy for tumor-related reasons or lack of follow-up. INTERVENTION: Intracorporeal or extracorporeal anastomosis was performed, based on availability of the robotic stapler and appropriate bedside assistance. MAIN OUTCOME MEASURES: The primary outcome was incisional hernia, diagnosed either clinically or on postoperative imaging, and analyzed using time-to-event analysis. A Cox proportional hazards model was used for multivariable analysis. Secondary outcomes were analyzed using parametric and nonparametric tests. Statistical significance was set at p < 0.05. RESULTS: Of 164 patients who met all inclusion criteria, 67 had intracorporeal and 97 had extracorporeal anastomoses. Median follow-up time was similar in both groups (14 vs 15 mo; p = 0.73). The 1-year estimated incisional hernia rate was 12% for extracorporeal and 2% for intracorporeal anastomoses (p = 0.007); this difference was confirmed by multivariable modeling. The severity of postoperative complications was similar between the groups, but there was an increase in incisional infections and a shorter length of stay (1 day) for intracorporeal cases. LIMITATIONS: The study was limited by its retrospective, single-surgeon nature. CONCLUSIONS: Right colectomy with intracorporeal anastomosis and a Pfannenstiel extraction site may reduce the rate of incisional hernias compared with extracorporeal anastomosis with a vertical midline extraction site. The intracorporeal approach was also associated with a decreased length of stay but an increase in incisional surgical site infections. These findings have implications for healthcare use and patient-centered outcomes. See Video Abstract at http://links.lww.com/DCR/B147. ANASTOMOSIS INTRACORPÓREAS EN COLECTOMÍAS DERECHAS MÍNIMAMENTE INVASIVAS SE ASOCIAN CON MENOS HERNIAS INCISIONALES Y UNA ESTADÍA HOSPITALARIA MÁS BREVE: nastomosis intracorpórea se asocia con varios beneficios a corto plazo. Sin embargo, es un procedimiento técnicamente desafiante con riesgos potenciales.nvestigar las diferencias en las complicaciones a corto plazo y las tasas de hernia incisional a largo plazo después de la colectomía robótica derecha con anastomosis intracorpórea versus extracorpórea y sitios de extracción estandarizados.Estudio de cohorte histórico.cirujano individual, institución única.Todos los pacientes sometidos a colectomía robótica derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel o anastomosis extracorpórea con un sitio de extracción vertical de la línea media de 2013-2017 fueron elegibles. Los criterios de exclusión fueron la conversión a laparotomía por razones relacionadas con el tumor o la falta de seguimiento.nastomosis intracorpórea o extracorpórea, según la disponibilidad de grapadora robótica y la asistencia adecuada quirúrgica.El resultado primario fue la hernia incisional, diagnosticada clínicamente o en imágenes postoperatorias, y analizada mediante análisis de tiempo hasta el evento. Se usó un modelo de riesgos proporcionales de Cox para el análisis multivariable. Los resultados secundarios se analizaron mediante pruebas paramétricas y no paramétricas. La significación estadística se estableció en p < 0,05.De 164 pacientes que cumplieron con todos los criterios de inclusión, 67 tenían anastomosis intracorpóreas y 97 tenían anastomosis extracorpóreas. La mediana del tiempo de seguimiento fue similar en ambos grupos (14 versus 15 meses, p = 0,73). La tasa de hernia incisional estimada para un año fue del 12% para las anastomosis extracorpóreas y del 2% para las anastomosis intracorpóreas (p = 0,007); esta diferencia fue confirmada por el modelado multivariable. La gravedad de las complicaciones postoperatorias fue similar entre los grupos, pero hubo un aumento de las infecciones incisionales y una estancia más corta (un día) para los casos intracorpóreos.Retrospectiva, cirujano único.a colectomía derecha con anastomosis intracorpórea y un sitio de extracción de Pfannenstiel puede reducir la tasa de hernias incisionales en comparación con la anastomosis extracorpórea con un sitio de extracción vertical en la línea media. El enfoque intracorpóreo también se asoció con una disminución de la duración de la estadía, pero con un aumento de las infecciones del sitio quirúrgico incisional. Estos hallazgos tienen implicaciones para la utilización de recursos médicos y beneficios para pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B147. (Traducción-Dr. Adrian Ortega).

Evolving application of minimally invasive cancer operations at a tertiary cancer center.

BACKGROUND: Patients and providers are increasingly interested in the utilization, safety, and efficacy of minimally invasive surgery (MIS). We reviewed 11 years of MIS resections (laparoscopic and robotic) for intra-abdominal malignancies. METHODS: Patients who underwent gastrectomy, distal pancreatectomy, hepatic resection, and colorectal resection between 2004 and 2014 were identified. Cases were categorized as open, laparoscopic, and robotic based on the initial operation approach. Diagnostic laparoscopies were excluded. RESULTS: Of the 10 039 patients who underwent the above procedures, between 2004 and 2014, 2832 (28%) were MIS. In 2004, 12% (100/826) of all resections were performed with MIS approaches, rising to 23% (192/821) of all resections by 2009 and 44% (484/1092) in 2014. The number of open resections has remained largely stable: 726 (88% of all resections) in 2004 and 608 (56% of all resections) in 2014. Initially, laparoscopy experienced incremental adoption. Robotic surgery was implemented in 2009 and is currently the dominant MIS approach, accounting for 76% (368/484) of all MIS resections in 2014. Overall mortality has remained less than 1%. CONCLUSIONS: While maintaining patient safety, utilization of MIS techniques has increased substantially since 2004, particularly for gastric and colorectal resections. Since 2009 robotic surgery is the predominant MIS approach.

Vestibular function in families with inherited autosomal dominant hearing loss.

The inner ear contains the developmentally related cochlea and peripheral vestibular labyrinth. Given the similar physiology between these two organs, hearing loss and vestibular dysfunction may be expected to occur simultaneously in individuals segregating mutations in inner ear genes. Twenty-two different genes have been discovered that when mutated lead to non-syndromic autosomal dominant hearing loss. A review of the literature indicates that families segregating mutations in 13 of these 22 genes have undergone formal clinical vestibular testing. Formal assessment revealed vestibular dysfunction in families with mutations in ten of these 13 genes. Remarkably, only families with mutations in the COCH and MYO7A genes self-report considerable vestibular challenges. Families segregating mutations in the other eight genes do not self-report significant balance problems and appear to compensate well in everyday life for vestibular deficits discovered during formal clinical vestibular assessment. An example of a family (referred to as the HL1 family) with progressive hearing loss and clinically-detected vestibular hypofunction that does not report vestibular symptoms is described in this review. Notably, one member of the HL1 family with clinically-detected vestibular hypofunction reached the summit of Mount Kilimanjaro.

Perianal pyoderma gangrenosum after excision and fulguration of anal condyloma acuminatum.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare, inflammatory skin pathology frequently associated with systemic inflammatory disease. While rare after surgery, recognition of this disease in the post-surgical setting is important as it can mimic wound infection. PRESENTATION OF CASE: We herein present a dramatic presentation of perianal PG four days after routine excision and fulguration of anal condyloma acuminatum. The affected area did not improve with broad spectrum antibiotics or surgical debridement. A diagnosis of PG was made from clinical suspicion and pathology findings, and further confirmed with rapid improvement after starting steroids. Diagnosis of this disease in the postoperative period requires high suspicion when the characteristic ulcerative or bullae lesions are seen diffusely and show minimal improvement with antibiotic treatment or debridement. DISCUSSION: Our case highlights the importance of recognizing this disease in the post-operative period, to allow for early initiation of appropriate treatment and prevent unnecessary surgical debridement of a highly sensitive area. There have been 32 case reports of PG in the colorectal literature, mostly following stoma creation. There is one case report of idiopathic perianal pyoderma gangrenosum with no known prior trauma. To our knowledge there are no previously reported cases of perianal PG after routine elective anorectal surgery. CONCLUSION: This is the first reported case of perianal pyoderma gangrenosum in the post-surgical setting. Increased awareness of pyoderma gangrenosum in the surgical literature will aid in prompt diagnosis and proper medical management of this uncommon postoperative morbidity.