Localizing ureteral catheters for left-sided colectomy and proctectomy: Do the risks justify the benefits?

BACKGROUND: The role of ureteral catheters in left-sided colectomies and proctectomies remains debated. Given the rarity of ureteral injury, prior retrospective studies were underpowered to detect potentially small, but meaningful differences. This study seeks to determine the role and morbidity of ureteral catheters in left-sided colectomy and proctectomy using a large, national database. METHODS: The National Surgical Quality Improvement Project from 2012 to 2018 was queried. Left-sided colectomies or proctectomies were included. Propensity score matching and multivariable logistic regression analysis was performed. RESULTS: 8419 patients with ureteral catherization and 128,021 patients without catheterization were included. After matching, there was not a significant difference in ureteral injury between the groups (0.7% with vs 0.9% without, p = 0.07). Ureteral catheters were associated with increased overall morbidity and longer operative time. Increasing body mass index, operations for diverticular disease, conversion to open, T4 disease and increasing operative complexity were associated with ureteral injury (p < 0.01 for all). CONCLUSIONS: Ureteral catheterization was not associated with decreased rates of ureteral injury when including all left-sided colectomies. High-risk patients for ureteral injury include those with obesity, diverticular disease, and conversion to open. Selective ureteral catheterization may be warranted in these settings.

Sexual Harassment and Cardiothoracic Surgery: #UsToo?

BACKGROUND: Fifty-eight percent of women in science, engineering, and medicine report being affected by sexual harassment (SH). This study sought to determine the extent of SH in cardiothoracic surgery. METHODS: The study developed a survey that was based on the Sexual Experience Questionnaire-Workplace, physician wellness, and burnout surveys. The survey was open to responses for 45 days and was disseminated through The Society of Thoracic Surgeons, Women in Thoracic Surgery, and Thoracic Surgery Residents Association listservs. A reminder email was issued at 28 days. Student t tests, Fisher exact tests, and χ2 tests were used to compare results. RESULTS: Of 790 respondents, 75% were male and 82% were attending surgeons. A total of 81% of female surgeons vs 46% of male attending surgeons experienced SH (P < .001). SH also was reported by trainees (90% female vs 32% male; P < .001). According to women, the most common offenders were supervising leaders and colleagues; for men, it was ancillary staff and colleagues. Respondents reported SH at all levels of training. A total of 75% of women surgeons vs 51% of men surgeons witnessed a colleague be subjected to SH; 89% of respondents reported the victim as female (male 2%, both 9%; P < .001). A total of 49% of female witnesses (50% of male witnesses) reported no intervention; less than 5% of respondents reported the offender to a governing board. SH was positively associated with burnout. CONCLUSIONS: SH is present in cardiothoracic surgery among faculty and trainees. Although women surgeons are more commonly affected, male surgeons also are subjected to SH. Despite witnessed events, intervention currently is limited. Policies, safeguards, and bystander training should be instituted to decrease these events.

EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice.

BACKGROUND: Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. METHODS: Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. RESULTS: A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members' online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. CONCLUSION: This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice.

Variation in Drain Management After Pancreatoduodenectomy: Early Versus Delayed Removal.

OBJECTIVE: The objectives are to report practice patterns and management of operatively placed drains and to compare outcomes in patients with early versus delayed drain removal after pancreatoduodenectomy. BACKGROUND: Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF). However, whether surgeons have altered their management based on this strategy is unknown. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2014 Participant Use File was queried to identify patients having undergone pancreatoduodenectomy (n = 3093). Patients with intraoperatively placed drains were stratified according to measurement of DFA-1 and day of drain removal. Patients with POD 1 DFA-1 of ≤5000 U/L whose drains were removed by POD 3 were propensity score-matched with patients whose drains were removed after POD 3. RESULTS: Of 2698 patients, 580 (21.5%) had a DFA-1 recorded. Measurement of DFA-1 was associated with earlier time to drain removal and shorter postoperative length of stay (P < 0.01). Propensity score matching revealed that early drain removal when DFA-1 was ≤5000 U/L was associated with significant (P < 0.05) reductions in overall morbidity (35.3% vs 52.3%), CR-POPF (0.9% vs 7.9%), and length of stay (6 vs 8 days). CONCLUSIONS: Significant variation exists in the use of drain fluid amylase in the management and timing of surgical drain removal after pancreatoduodenectomy. Clinical outcomes are best when drain fluid amylase is low and operatively placed drains are removed by POD 3.

Perioperative Management of Patients with Colovesical Fistula.

BACKGROUND: Colovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF. STUDY DESIGN: This is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89). RESULTS: Patients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months. CONCLUSIONS: There is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.

Echocardiographic Guidance During Neonatal and Pediatric Jugular Cannulation for ECMO.

BACKGROUND: Internal jugular vein extracorporeal membrane oxygenation (ECMO) cannula position is traditionally confirmed via plain film. Misplaced cannulae can result in need for repositioning and increased morbidity. Echocardiography (ECHO) may be used during cannulation as a more accurate means of guiding cannula position. This study reviews the effect of a protocol encouraging the use of ECHO at cannulation. METHODS AND MATERIALS: Single institution retrospective review of patients who received ECMO support using jugular venous cannulation. We compared those who underwent ECHO (ECHO+) at the time of cannulation with those who did not (ECHO-). RESULTS: Eighty-nine patients were included: 26 ECHO+, 63 ECHO-. Most ECHO+ patients underwent dual-lumen veno-venous (VV) cannulation (65%); 32% of ECHO- patients had VV support (P = 0.003). There was no difference in the rate of cannula repositioning between the two groups: 8% ECHO+ and 10% ECHO-, P = 0.78. In the VV ECMO subgroup, ECHO+ patients required no repositioning (0/17), while 20% (4/20) of ECHO- VV patients did (P = 0.10). After cannulation, there were 0.58 ECHO studies per patient to verify cannula position in the ECHO+ group compared with 0.22 in the ECHO- group (P = 0.02). Each group had a major mechanical complication: atrial perforation from a guidewire during cannulation in ECHO+ and late atrial perforation from a loose cannula in ECHO-, and there was no difference in minor complications. CONCLUSIONS: ECHO guidance during neonatal and pediatric jugular cannulation for ECMO did not decrease morbidity or reduce the need for cannula repositioning. ECHO may still be a useful adjunct for precise placement of a dual-lumen VV cannula and during difficult cannulations.

Contemporary Management of Sigmoid Volvulus.

BACKGROUND: Sigmoid volvulus is an uncommon cause of bowel obstruction that is historically associated with high morbidity and mortality. The objective of this study was to evaluate contemporary management of sigmoid volvulus and the safety of primary anastomosis in patients with sigmoid volvulus. METHODS: The National Surgical Quality Improvement Project from 2012 to 2015 was queried for patients with colonic volvulus who underwent left-sided colonic resection. A propensity score-matched analysis was performed to compare patients with sigmoid volvulus undergoing colectomy with primary anastomosis without proximal diversion to colectomy with end colostomy. RESULTS: Two thousand five hundred thirty-eight patients with sigmoid volvulus were included for analysis. Patients had a median age of 68 years (interquartile range, 55-80) and 79% were fully independent preoperatively. Fifty-one percent of operations were performed emergently. One thousand eight hundred thirteen (71%) patients underwent colectomy with anastomosis, 240 (10%) colectomy with anastomosis and proximal diversion, and 485 (19%) colectomy with end colostomy. Overall, 30-day mortality and morbidity were 5 and 40%, respectively. After propensity score matching, mortality, overall morbidity, and serious morbidity were similar between groups. CONCLUSIONS: Sigmoid volvulus occurs in elderly and debilitated patients with significant morbidity, mortality, and lifestyle implications. In selected patients, anastomosis without proximal diversion in patients with sigmoid volvulus results in similar outcomes to colectomy with end colostomy.

Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries.

PURPOSE: The utility of measuring the pediatric adjusted shock index (SIPA) at admission for predicting severity of blunt injury in pediatric patients has been previously reported. However, the utility of following SIPA after admission is not well described. METHODS: The trauma registry from a level-one pediatric trauma center was queried from January 1, 2010 to December 31, 2015. Patients were included if they were between 4 and 16years old at the time of admission, sustained a blunt injury with an Injury Severity Score≥15, and were admitted less than 12h after their injury (n=286). Each patient's SIPA was then calculated at 0, 12, 24, 36, and 48h after admission and then categorized as elevated or normal at each time frame based upon previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed. RESULTS: In patients with a normal SIPA at arrival, 18.4% of patients who developed an elevated SIPA at 12h after admission died, whereas 2.4% of patients who maintained a normal SIPA throughout the first 48h of admission died (p<0.01). Among patients with an elevated SIPA at arrival, increased length of time to normalize SIPA correlated with increased length of stay (LOS) and intensive care unit (ICU) LOS. Similarly, elevation of SIPA after arrival in patients with a normal initial SIPA correlated to increased LOS and ICU LOS. CONCLUSIONS: Patients with a normal SIPA at time of arrival who then have an elevated SIPA in the first 24h of admission are at increased risk for morbidity and mortality compared to those whose SIPA remains normal throughout the first 48h of admission. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS, ICU LOS, and other markers of morbidity across a mixed blunt trauma population. Whether trending SIPA early in the hospital course serves only as a marker for injury severity or if it has utility as a resuscitation metric has not yet been determined. TYPE OF STUDY: Prognostic. LEVEL OF EVIDENCE: Level II.

Assessing the impact of conversion on outcomes of minimally invasive distal pancreatectomy and pancreatoduodenectomy.

BACKGROUND: Our aim was to compare outcomes of patients who undergo conversion to open during minimally invasive distal pancreatectomy (MI-DP) and pancreatoduodenectomy (MI-PD) to those completed in minimally invasive fashion, and to compare outcomes of minimally invasive completions and conversions to planned open pancreatectomy. METHODS: Propensity scoring was used to compare outcomes of completed and converted cases from a national cohort, and multivariate regression analysis (MVA) was used to compare minimally invasive completions and conversions to planned open pancreatectomy. RESULTS: MI-DP was performed in 43.0%. Conversions (20.2%) had increased morbidity (32.3 vs 42.0%), serious morbidity (11.1 vs 21.2%), and organ space infection (6.2 vs 14.2%). Outcomes of MI-DP conversions were comparable to open. MI-PD was performed in 6.1%. Conversions (25.2%) had increased organ space infection (10.9 vs 26.6%), blood transfusions (17.2 vs 42.2%), and clinically relevant pancreatic fistula (11.5 vs 28.1%). On MVA, conversion of MI-PD was associated with increased mortality (OR 2.84, 95% CI 1.09-7.42), post-operative percutaneous drain placement (OR 2.36, 95% CI 1.32-4.20), and blood transfusions (OR 1.85, 95% CI 1.07-3.21). CONCLUSION: Converted cases have increased morbidity compared to completions, and for patients undergoing PD, conversions may be associated with inferior outcomes compared to planned open cases.

Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury.

OBJECTIVE: The purpose of this study was to understand the contemporary trends of splenectomy in blunt splenic injury (BSI) and to determine if angiography and embolization (ANGIO) may be impacting the splenectomy rate. BACKGROUND: The approach to BSI has shifted to increasing use of nonoperative management, with a greater reliance on ANGIO. However, the impact ANGIO has on splenic salvage remains unclear with little contemporary data. METHODS: The National Trauma Data Bank was used to identify patients 18 years and older with high-grade BSI (Abbreviated Injury Scale >II) treated at Level I or II trauma centers between 2008 and 2014. Primary outcomes included yearly rates of splenectomy, which was defined as early if performed within 6 hours of ED admission and delayed if greater than 6 hours, ANGIO, and mortality. Trends were studied over time with hierarchical regression models. RESULTS: There were 53,689 patients who had high-grade BSI over the study period. There was no significant difference in the adjusted rate of overall splenectomy over time (24.3% in 2008, 24.3% in 2014, P value = 0.20). The use of ANGIO rapidly increased from 5.3% in 2008 to 13.5% in 2014 (P value < 0.001). Mortality was similar overtime (8.7% in 2008, 9.0% in 2014, P value = 0.33). CONCLUSION: Over the last 7 years, the rate of angiography has been steadily rising while the overall rate of splenectomy has been stable. The lack of improved overall splenic salvage, despite increased ANGIO, calls into question the role of ANGIO in splenic salvage on high-grade BSI at a national level.

Sclerotherapy for the management of rectal prolapse in children.

PURPOSE: Rectal prolapse is a commonly occurring and usually self-limited process in children. Surgical management is indicated for failures of conservative management. However, the optimal approach is unknown. The purpose of this study is to determine the efficacy of sclerotherapy for the management of rectal prolapse. METHODS: This was a retrospective review of children <18years with rectal prolapse who underwent sclerotherapy, predominantly with peanut oil (91%), between 1998 and 2015. Patients with imperforate anus or cloaca abnormalities, Hirschprung disease, or prior pull-through procedures were excluded. RESULTS: Fifty-seven patients were included with a median age of 4.9years (interquartile range (IQR) 3.2-9.2) and median follow-up of 52months (IQR 8-91). Twenty patients (n=20/57; 35%) recurred at a median of 1.6months (IQR 0.8-3.6). Only 3 patients experienced recurrence after 4months. Nine of the patients who recurred (n=9/20; 45%) were re-treated with sclerotherapy. This was successful in 5 patients (n=5/9; 56%). Two patients (n=2/20; 10%) experienced a mucosal recurrence which resolved with conservative management. Forty-four patients were thus cured with sclerotherapy alone (n=44/57; 77%). No patients undergoing sclerotherapy had an adverse event. Thirteen patients (n=13/20; 65%) underwent rectopexy after failing at least one treatment of sclerotherapy. Three of these patients (n=3/13; 23%) recurred following rectopexy and required an additional operation. CONCLUSIONS: Injection sclerotherapy for children with rectal prolapse resulted in a durable cure of prolapse in most children. Patients who recur following sclerotherapy tend to recur within 4months. Another attempt at sclerotherapy following recurrence is reasonable and was successful half of the time. Sclerotherapy should be the preferred initial treatment for rectal prolapse in children and for the initial treatment of recurrence. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Treatment Study.

Gender differences in academic surgery, work-life balance, and satisfaction.

BACKGROUND: An increasing number of women are pursuing a career in surgery. Concurrently, the percentage of surgeons in dual-profession partnerships is increasing. We sought to evaluate the gender differences in professional advancement, work-life balance, and satisfaction at a large academic center. MATERIALS AND METHODS: All surgical trainees and faculty at a single academic medical center were surveyed. Collected variables included gender, academic rank, marital status, family size, division of household responsibilities, and career satisfaction. Student t-test, Fisher's exact test, and chi-square test were used to compare results. RESULTS: There were 127 faculty and 116 trainee respondents (>80% response rate). Respondents were mostly male (77% of faculty, 58% of trainees). Women were more likely than men to be married to a professional (90% versus 37%, for faculty; 82% versus 41% for trainees, P < 0.001 for both) who was working full time (P < 0.001) and were less likely to be on tenure track (P = 0.002). Women faculty were more likely to be primarily responsible for childcare planning (P < 0.001), meal planning (P < 0.001), grocery shopping (P < 0.001), and vacation planning (P = 0.003). Gender-neutral responsibilities included financial planning (P = 0.04) and monthly bill payment (P = 0.03). Gender differences in division of household responsibilities were similar in surgical trainees except for childcare planning, which was a shared responsibility. CONCLUSIONS: Women surgeons are more likely to be partnered with a full-time working spouse and to be primarily responsible for managing their households. Additional consideration for improvement in recruitment and retention strategies for surgeons might address barriers to equalizing these gender disparities.

Medication Errors in Injured Patients.

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

The model for end-stage liver disease predicts outcomes in patients undergoing cholecystectomy.

BACKGROUND: The magnitude of risk for patients undergoing cholecystectomy with high model for end-stage liver disease (MELD) scores is poorly understood. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013 was used to study patients undergoing cholecystectomy. Patients were excluded if they had choledocholithiasis or preoperative dialysis. Bivariate data analysis was performed and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: A total of 63,464 patients were included in the study. Unadjusted mortality significantly increased as the MELD score increased in the laparoscopic (MELD = 6-10, 0.2%; 11-15, 1.1%; 16-20, 3.2%; >20, 5.8%) and open groups (MELD = 6-10, 1.5%; 11-15, 3.7%; 16-20, 8.6%; >20, 17.9%) (p-value <0.001 for both). Unadjusted morbidity also increased with MELD score increases in the laparoscopic (MELD = 6-10, 3.8%; 11-15, 9.9%; 16-20, 16.3%; >20, 22.8%) and open groups (MELD = 6-10, 18.7%; 11-15, 28.2%; 16-20, 40.7%; >20, 57.8%) (p-value <0.001 for both). Patients with ascites and high MELD scores had higher rates of mortality (laparoscopic, MELD > 20, 33.3%; open, MELD > 20, 48.5%) and morbidity (laparoscopic, MELD > 20, 66.7%; open, MELD > 20, 75.8%) across all MELD scores. After adjustment, MELD score acted as a progressive and independent predictor of morbidity and mortality. CONCLUSIONS: The MELD score is an objective and easy to calculate scoring system that independently predicts postoperative morbidity and mortality in patients undergoing cholecystectomy. Patients with ascites have substantially worse outcomes across all MELD scores. Open cholecystectomy is associated with significantly more morbidity and mortality than laparoscopic cholecystectomy across all MELD groups.

Impact of integrated programs on general surgery operative volume.

BACKGROUND: Integrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. METHODS: Case logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. RESULTS: Integrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009-2010 to 1392 in 2015-2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. CONCLUSIONS: Multiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents.

Contemporary short- and long-term outcomes in patients with unremitting constipation and fecal incontinence treated with an antegrade continence enema.

PURPOSE: The primary aim of this study is to determine the natural history of patients who undergo an antegrade continence enema (ACE) procedure including complications, functional results, and long-term outcomes. METHODS: Patients aged 3-18years who underwent an ACE procedure from 2008 to 2015 for unremitting constipation and fecal incontinence with at least thirty day follow-up were included. Patients with congenital anatomic disorders of the spine, rectum, and anus were excluded. RESULTS: A total of 93 patients were included in the analysis with an average age of 10+/-4years and follow-up of 26+/-41months. The ACE procedure was rapidly effective, with 99% of patients experiencing improvement at 1month. At the end of follow-up, 83% of patients had normal bowel function, and 95% of patients noted improvement. Amongst patients with at least 24months of follow-up (n=51), 43% successfully stopped using their ACE at an average of 40+/-27months. Overall morbidity was 55%, mostly related to minor complications. However, 13% of patients required an additional operation. CONCLUSION: The ACE procedure is very successful in the treatment of unremitting constipation with fecal incontinence in appropriately selected patients. LEVEL OF EVIDENCE: Level IV.

Bowel Preparation Is Associated with Reduced Morbidity in Elderly Patients Undergoing Elective Colectomy.

BACKGROUND: Bowel preparation in elderly patients is associated with physiologic derangements that may result in postoperative complications. The aim of this study is to determine the impact of bowel preparation on postoperative outcomes in elderly patients. METHODS: Patients age 75 years and older who underwent elective colectomy were identified from the 2012-2014 American College of National Surgical Quality Improvement Program (ACS-NSQIP database). Patients were grouped into no bowel preparation, mechanical bowel preparation (MBP), oral antibiotic preparation (OABP), or combined MBP + OABP. Logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: There were 4829 patients included in the analysis. Morbidity was 34.3% in no bowel prep, 32.4% in MBP, 24.8% in OABP, and 24.6% in MBP + OABP groups (p < 0.001). The MBP + OABP group compared with no bowel prep was associated with reduced rates of anastomotic leak, ileus, superficial surgical site infection (SSI), organ space SSI, respiratory compromise, and reduced length of stay. There was no difference in the rate of acute kidney injury between the groups. CONCLUSION: MBP + OABP was associated with reduced morbidity compared with no bowel preparation in elderly patients undergoing elective colorectal resection. MBP alone was not associated with differences in outcomes compared with no bowel preparation. The use of MBP + OABP is safe and effective in elderly patients undergoing elective colectomy.

Laparoscopic versus robotic colectomy: a national surgical quality improvement project analysis.

INTRODUCTION: Robotic colorectal surgery is being increasingly adopted. Our objective was to compare early postoperative outcomes between robotic and laparoscopic colectomy in a nationally representative sample. METHODS: The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Dataset from 2012 to 2014 was used for this study. Adult patients undergoing elective colectomy with an anastomosis were included. Patients were stratified based on location of colorectal resection (low anterior resection (LAR), left-sided resection, or right-sided resection). Bivariate data analysis was performed, and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: There were a total of 25,998 laparoscopic colectomies (30 % LAR's, 45 % left-sided, and 25 % right-sided) and 1484 robotic colectomies (54 % LAR's, 28 % left-sided, and 18 % right-sided). The risk-adjusted overall morbidity, serious morbidity, and mortality were similar between laparoscopic and robotic approaches in all anastomotic groups. Patients undergoing robotic LAR had a lower conversion rate (OR 0.47, 95 % CI 1.20-1.76) and postoperative sepsis rate (OR 0.49, 95 % CI 0.29-0.85) but a higher rate of diverting ostomies (OR 1.45, 95 % CI 1.20-1.76). Robotic right-sided colectomies had significantly lower conversion rates (OR 0.58, 95 % CI 0.34-0.96). Robotic colectomy in all groups was associated with a longer operative time (by 40 min) and a decreased length of stay (by 0.5 days). CONCLUSIONS: In a nationally representative sample comparing laparoscopic and robotic colectomies, the overall morbidity, serious morbidity, and mortality between groups are similar while length of stay was shorter by 0.5 days in the robotic colectomy group. Robotic LAR was associated with lower conversion rates and lower septic complications. However, robotic LAR is also associated with a significantly higher rate of diverting ostomy. The reason for this relationship is unclear. Surgeon factors, patient factors, and technical factors should be considered in future studies.