Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

All-cause 30- and 90-day inpatient readmission costs associated with 4 minimally invasive colon surgery approaches: A propensity-matched analysis using Medicare and commercial claims data.

Background: The purpose of this study is to assess which minimally invasive colon surgery approach may be associated with the least 30- and 90-day inpatient readmission costs from a payer perspective. Methods: This retrospective claims analysis included adult Medicare and commercially insured beneficiaries who underwent minimally invasive sigmoid, left, or right colon surgery between January 2016 and December 2019. Two cohorts were created based on the use of near-infrared fluorescence (NIF) and were propensity-score matched 1 NIF:5 NoNIF. Four subgroups were then created based on the presence of robotics (R): NIF-NoR, NIF-R, NoNIF-R, and NoNIF-NoR. Results: A total of 50,148 patients were identified, of which 165 (0.3%) indicated the use of NIF and 49,983 (99.7%) did not. After propensity score matching, 990 patients were included (NIF cohort: 165; NoNIF cohort: 825). Of the 165 NIF patients, 87 were robotic-assisted and 78 were conventional laparoscopy. Of the 825 NoNIF patients, 136 were robotic-assisted and 689 were conventional laparoscopy. Postindex inpatient readmission costs were significantly different between the NIF and NoNIF cohorts with the NIF cohort having the lowest 30- and 90-day postindex readmission costs. Postindex readmission costs were also significantly different across the 4 subgroups at 30 and 90 days, with the NIF-NoR group having the lowest postindex readmission costs (all P < .05). Conclusion: Using NIF without the robot during minimally invasive colon surgery is associated with the least 30- and 90-day inpatient readmission costs compared to the other 3 approaches. Hospitals may want to consider these potential cost savings when evaluating technologies for laparoscopic colon surgery. Key Message: Near-infrared fluorescence (NIF) imaging without the robot during minimally invasive colon surgery may significantly save hospitals 30- and 90-day inpatient readmission costs compared to NIF with the robot, NoNIF with the robot, and NoNIF without the robot. This is important as hospitals may want to consider these cost findings in addition to capital equipment and disposable costs when evaluating technologies for laparoscopic colon surgery.

Surgical outcomes following pancreatic resection at a low-volume community hospital: do all patients need to be sent to a regional cancer center?

BACKGROUND: The only curative option for patients with pancreatic cancer is surgical resection. The potential for significant morbidity and mortality following these procedures along with short-term survival benefit has called into question the role of surgery in this disease. Several recent reports have shown that morbidity, mortality, and survival can be improved if these pancreatic resections are performed at centers where large volumes of cases are done annually. METHODS: A retrospective review of the tumor registry from 1994 to 2003 identified 242 cases of pancreatic cancer diagnosed and/or treated at our institution. During this period, 31/242 (13%) patients underwent surgical resection. Patients' charts were reviewed for diagnosis, stage of tumor, presenting symptoms, surgery, length of stay, and survival. Morbidity and mortality rates were calculated for all patients. RESULTS: Thirty-one resections were performed in 16 males and 15 females. The median age at presentation was 69 years. The most common presenting symptom was painless jaundice. A pancreaticoduodenectomy was the most common procedure (n = 24), while 7 distal pancreatectomies were also performed. Eight surgeons performed the 31 resections with one surgeon performing 12 of the cases. The median length of stay was 16 days. Complications arose in 15/31 (48%) patients. There was no 30-day surgical or in-hospital mortality. CONCLUSIONS: Major pancreatic surgery can be performed safely at community hospitals. It is imperative that each hospital is responsible for providing morbidity and mortality figures related to pancreatic procedures performed at their institution. In this changing climate of reimbursement and pay for performance, institutions that do not do this may be required to send these cases to regional centers.