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The integration of robotic-assisted surgery (RAS) has transformed various surgical disciplines, including more recently plastic surgery. While RAS has gained acceptance in multiple specialties, its integration in plastic surgery has been gradual, challenging traditional open methods. Robotic-assisted deep inferior epigastric perforator (DIEP) flap breast reconstruction is a technique aimed to overcome drawbacks associated with the traditional open DIEP flap approach. These limitations include a relatively large fascial incision length, potentially increasing rates of postoperative pain, abdominal bulge, hernia rates, and core weakening. The robotic-assisted DIEP flap technique emerges as an innovative and advantageous approach in fascial-sparing abdominal based autologous breast reconstruction. While acknowledging certain challenges such as increased operative time, ongoing refinements are expected to further improve the overall surgical experience, optimize results, and solidify the role of robotics in advancing reconstructive microsurgical procedures in plastic surgery. Herein, the authors provide an overview of robotic surgery in the context of plastic surgery and its role in the DIEP flap harvest for breast reconstruction.
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BACKGROUND: Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the United States. Our aim was to determine if increased operative time (OT) is associated with increased morbidity following laparoscopic cholecystectomy. METHODS: Using ACS NSQIP from 2006 to 2015, we identified all adult (≥18 years) patients that underwent laparoscopic cholecystectomy for cholecystitis performed within 3 days of admission. Our analysis was limited to cases with OT ≥15 minutes and ≤360 minutes. Outcome variables included postoperative surgical site infections (SSI), dehiscence, pneumonia, reintubation, failure to wean from ventilator, pulmonary embolism, renal failure, urinary tract infection, cardiac arrest, myocardial infarct, bleeding, deep vein thrombosis, sepsis, septic shock, return to the operating room, and death. RESULTS: 7,031 cases met inclusion criteria. Median OT was 63 minutes, first quartile was 46 minutes and third quartile was 87 minutes. Logistic regression analysis showed that increased OT (third vs first quartile) was an independent risk factor for superficial SSI (OR 1.75, 95% CI 1.36-2.25, P < .0001), organ-space SSI (OR 1.77, 95% CI 1.33-2.35, P < .0001), dehiscence (OR 2.03, 95% CI 1.01-4.07, P = 0.0470), and septic shock (OR 1.81, 95% CI 1.06-3.09, P = 0.0286). Increased OT was independently associated with increased LOS (fourth vs 1st quartile: IRR 1.53, P < 0.0001; third vs 1st quartile: IRR 1.29, P < .0001; 2nd vs 1st quartile: IRR 1.16, P < 0.0001). CONCLUSION: Increased OT is independently associated with morbidity and increased LOS following laparoscopic cholecystectomy for cholecystitis. Prospective studies are warranted to determine which factors contribute to increased OT and why.
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Colecistectomia Laparoscópica , Colecistite , Laparoscopia , Choque Séptico , Adulto , Humanos , Estados Unidos/epidemiologia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Duração da Cirurgia , Laparoscopia/métodos , Infecção da Ferida Cirúrgica/etiologia , Colecistite/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos RetrospectivosRESUMO
In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.
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INTRODUCTION: We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias. METHODS: Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region. RESULTS: 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0 days. Univariate analysis comparing operation <1 day to ≥1 day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure. CONCLUSION: Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.
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Hérnia Ventral , Medicare , Adulto , Humanos , Feminino , Idoso , Masculino , Estados Unidos , Hérnia Ventral/complicações , Hospitalização , Pacientes Internados , Renda , Estudos Retrospectivos , Tempo de InternaçãoRESUMO
Background: The prevalence of patients with end stage renal disease (ESRD) requiring general surgical procedures is increasing. Our aim was to explore the effect of ESRD on patients undergoing elective laparoscopic ventral hernia repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program (2010-2015) database was used to identify patients who underwent elective laparoscopic ventral hernia repair. Multivariable analysis was performed adjusting for risk variables including age, gender, race, comorbidity status, body mass index ≥ 35, and presence of ESRD. Results: A total of 8,789 patients undergoing elective laparoscopic ventral hernia repair were identified. Sixty-four patients (0.73%) had ESRD. ESRD was identified as an independent risk factor for postoperative pneumonia (odds ration [OR] 6.91, p = 0.00363), sepsis (OR 18.58, p = 0.000286), and length of stay (IRR 1.63, 95% confidence interval 1.19 - 2.27, p = 0.0036). Conclusions: ESRD patients undergoing elective laparoscopic ventral hernia repair had an increased risk of postoperative pneumonia, sepsis, and length of stay. Clinicians should be cognizant of these risks when performing elective operations on ESRD patients.
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Hérnia Ventral , Falência Renal Crônica , Laparoscopia , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Humanos , Falência Renal Crônica/complicações , Laparoscopia/métodos , Complicações Pós-Operatórias/etiologiaRESUMO
INTRODUCTION: Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation. MATERIALS AND METHODS: Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed. RESULTS: 4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death. DISCUSSION: Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.
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Doenças do Colo/mortalidade , Doenças do Colo/cirurgia , Hospitalização , Perfuração Intestinal/mortalidade , Perfuração Intestinal/cirurgia , Transferência de Pacientes , Tempo para o Tratamento , Idoso , Instituições de Assistência Ambulatorial , Anastomose Cirúrgica , Colectomia , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Instituições Residenciais , Fatores de RiscoRESUMO
INTRODUCTION: Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively. MATERIALS AND METHODS: Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables. RESULTS: 2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score (P < .0001) and large hospital size (P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income (P = .0022) and weekend admission (P = .048). DISCUSSION: There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.
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Mortalidade Hospitalar , Hospitalização , Obstrução Intestinal/cirurgia , Tempo de Internação , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Despite the increased adoption of minimally invasive techniques in colorectal surgery, an open resection with ostomy creation remains an accepted operation for perforated diverticulitis. In the United States, there is an increase in the rates of both morbid obesity and diverticular disease. Therefore, we wanted to explore whether outcomes for morbidly obese patients with diverticulitis are worse than nonmorbidly obese patients after open colectomy for diverticulitis. MATERIALS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015, we identified adults with emergent admission for diverticulitis (International Classification of Diseases, Ninth Revision, code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification, in which a resection with ostomy (Current Procedural Terminology codes 44141, 44143, or 44144) was performed. We excluded cases with age >90 y, ventilator dependence, evidence of disseminated cancer and missing sex, race, body mass index, functional status, American Society of Anesthesiologists class, length of stay (LOS), or operative time data. Morbid obesity was defined as body mass index >35 kg/m2. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-d postoperative complications, and mortality. Univariate and propensity scores with postmatching analyses were performed. RESULTS: A total of 2019 patients met inclusion and exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 versus 62.6 y) and female (54.5% versus 45.5%). Morbidly obese patients also had higher rates of insulin-dependent diabetes (8.0% versus 4.2%), hypertension (60.1% versus 51.3%), renal failure (3.4% versus 1.5%), and higher American Society of Anesthesiologists class (class 4: 23.5% versus 19.6% and class 5: 1.45% versus 0.87%). Morbidly obese patient had no increase in 30-d mortality or LOS, but they had higher rates of superficial wound infection (9.0% versus 5.8%; P = 0.0259), deep wound infection (4.4% versus 1.9%; P = 0.0073), acute renal failure (4.8% versus 2.4%; P = 0.0189), postoperative septic shock (17.7% versus 12.1%; P = 0.0040), and return to the operating room (11.1% versus 6.4%; P = 0.0015). We identified 397 morbidly obese patients well matched by propensity score to 397 nonmorbidly obese patients. Conditional logistic regression showed no difference in LOS (median 12.9 versus 12.4 d; P = 0.4648) and no increased risk of 30-d mortality (P = 0.947), but morbid obesity was an independent predictor for return to the operating room (adjusted odds ratio: 27.09 [95% confidence interval: 2.68-274.20]; P = 0.005). CONCLUSIONS: This analysis of a large national clinical database demonstrates that morbidly obese patients presenting with perforated diverticulitis undergoing a Hartmann's procedure do not have increased mortality or LOS compared with nonobese patients. After adjusting for the effects of morbid obesity, morbidly obese patients had increased risk of return to operating room. Despite literature describing the many perioperative risks of obesity, our analysis showed only increased reoperation for obese patients with diverticulitis.
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Colostomia/efeitos adversos , Doença Diverticular do Colo/cirurgia , Perfuração Intestinal/cirurgia , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Sepse/cirurgia , Adulto , Idoso , Índice de Massa Corporal , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/mortalidade , Feminino , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Período Perioperatório/mortalidade , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sepse/etiologia , Sepse/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS: Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS: Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS: Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.
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Nível de Saúde , Obstrução Intestinal/cirurgia , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso de 80 Anos ou mais , Conversão para Cirurgia Aberta/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Obstrução Intestinal/mortalidade , Intestino Delgado/cirurgia , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Fatores Sexuais , Aderências Teciduais/mortalidade , Aderências Teciduais/cirurgia , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates and ESRD status has been associated with increased morbidity and mortality in other operations. Using a national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy. We identified adult and emergent patients with perforated duodenal and gastroduodenal ulcers that underwent omentopexy using the 2005 to 2012 Nationwide Inpatient Sample. We identified patients with ESRD status and assessed comorbidity status using the Elixhauser-van Walraven score. Univariate and multivariable logistic regression analyses were performed. Inpatient mortality was the primary outcome. Six thousand five hundred and twenty-one patients were identified. Median age was 59.0 years, majority were male (55.56%), 79 (1.21%) patients had ESRD, 367 (5.63%) patients died during admission. Multivariable logistic regression showed age (OR 2.71, P < 0.0001), Elixhauser-van Walraven score (OR 2.69, P < 0.0001), and ESRD status (OR 3.88, P < 0.0001) as independent risk factors for mortality. ESRD was associated with increased mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. Future studies are necessary to identify methods to increase perioperative survival.
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Falência Renal Crônica/complicações , Úlcera Péptica Perfurada/complicações , Úlcera Péptica Perfurada/mortalidade , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/mortalidade , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Omento/cirurgia , Úlcera Péptica Perfurada/cirurgia , Estudos Retrospectivos , Fatores de RiscoRESUMO
End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multivariate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.
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Colecistectomia Laparoscópica/efeitos adversos , Colecistite Aguda/cirurgia , Complicações Intraoperatórias/epidemiologia , Falência Renal Crônica/complicações , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Colecistite Aguda/complicações , Colecistite Aguda/mortalidade , Feminino , Preços Hospitalares , Humanos , Falência Renal Crônica/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores SocioeconômicosRESUMO
BACKGROUND AND OBJECTIVES: Ventral hernia repair is one of the most commonly performed general surgery procedures, and minimally invasive approaches are increasingly preferred. The physiologic repair offered by the preperitoneal approach is favorable, with reduced complications, but it remains a technical challenge. The robotic platform allows for enhanced instrument flexibility and ease of operation. We conducted a retrospective review of our experience with robotic transabdominal preperitoneal repair (rTAPP) versus robotic intraperitoneal onlay mesh (rIPOM) at a tertiary care hospital in an urban setting. METHODS: We reviewed the records of patients undergoing minimally invasive ventral hernia repair from March 2014 through March 2017. Demographics, complication rates, and operative time were compared by t test and Chi square test, as applicable. RESULTS: Sixty-three patients met the criteria for inclusion in the study. Of those, 27 underwent ventral hernia repair with rIPOM and 36 with rTAPP, with no major intraoperative complications. There were no significant differences in demographics between the 2 groups in age, BMI, and sex. The difference in mean operative time was not significant (rIPOM 167.26 [SD 51.76] minutes vs rTAPP 158.84 minutes [SD 61.5]; P = .57), whereas mean console time was significantly different (rIPOM 70.88 minutes [SD 32.88] vs rTAPP 90.26 [SD 31.17]; P = .018). Postoperative complications occurred only with rIPOM and included urinary retention, seroma, and fever. CONCLUSIONS: rTAPP is a promising alternative to rIPOM, with reduced complications without adding significant operative time, and may allow for reduced costs.
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Hérnia Ventral/cirurgia , Herniorrafia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Feminino , Seguimentos , Herniorrafia/instrumentação , Hospitais Urbanos , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/instrumentação , Provedores de Redes de Segurança , Telas Cirúrgicas , Centros de Atenção Terciária , Resultado do TratamentoRESUMO
In recent years, fluorescent cholangiography using Indocyanine green (ICG) dye has been used to aid identification of structures during robotic cholecystectomy. We sought to compare cholecystectomy with ICG dye versus laparoscopic cholecystectomy at an inner-city academic medical center. Between January 2013 and July 2016, we identified 287 patients of which 191 patients underwent laparoscopic cholecystectomy and 96 patients underwent robotic cholecystectomy with ICG dye. Preoperative risk variables of interest included age, sex, race, body mass index (BMI), and acute cholecystitis. Primary outcome of interest was conversion to open procedures while secondary outcome was length of stay. The two groups were similar in their BMI (31.98 vs. 31.10 kg/m2 for the laparoscopic and robotic, respectively, p = 0.32). The laparoscopic group had a greater mean age compared to the robotic group (47.77 vs. 43.61 years, p = 0.04). There was no significant difference in sex and emergency surgery between the two groups. Fewer open conversions were found in the robotic than the laparoscopic group [2 (2.1%) vs. 17 (8.9%), p = 0.03]. In multiple logistic regression, robotic cholecystectomy with ICG also showed a lower risk of conversion compared to laparoscopic cholecystectomy, but the difference did not reach statistical significance (OR 0.42, 95% CI 0.11-1.65, p = 0.22). ICG fluorescent cholangiography during robotic cholecystectomy may contribute to proper identification of biliary structures and may reduce the rates of open conversion. The preliminary results of fewer open conversions are promising. Further studies with a large randomized prospective controlled study should be taken for further evaluation.
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Colangiografia/métodos , Colecistectomia/métodos , Angiofluoresceinografia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Feminino , Corantes Fluorescentes/uso terapêutico , Doenças da Vesícula Biliar/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: The prevalence of end-stage renal disease (ESRD) has increased, and there is limited data on the risks faced by this patient population undergoing surgery. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program, we identified common surgical procedures undergone by patients with ESRD. These patients were compared with a matched-control group. A subanalysis was performed to determine the risk factors for returning to the operating room in patients with ESRD. RESULTS: Of the 195,585 patients identified, 1,163 had ESRD. ESRD was associated with increased mortality (odds ratio [OR] 9.05, confidence interval [CI] 4.09 to 20.00) and rates of return to the operating room (OR 2.97, CI 1.99 to 4.46). Returning to the OR was associated with increased operation times (98.9 vs 130.2 minutes, P < .05), mortality (OR 4.35, CI 2.11 to 8.99), and morbidity (OR 7.6, CI 4.68 to 12.41). CONCLUSIONS: Patients with ESRD face greater risks when entering the operating room, and further study is needed to elucidate preventable risk factors.
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Falência Renal Crônica/mortalidade , Reoperação/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Diálise Renal/efeitos adversos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The number of patients living with human immunodeficiency virus and acquired immunodeficiency syndrome is growing due to advances in antiretroviral therapy. Existing literature on appendectomy within this patient population has been limited by small sample sizes. Therefore, we used a large, multiyear, nationwide database to study this topic comprehensively. METHODS: Using the Nationwide Inpatient Sample, we identified 338,805 patients between 2005 and 2012 who underwent laparoscopic or open appendectomy for acute appendicitis. Interval appendectomies were excluded. We used multivariable adjusted regression models to test differences between patients with human immunodeficiency virus without acquired immunodeficiency syndrome and a reference group, as well as human immunodeficiency virus with acquired immunodeficiency syndrome and a reference group, with regard to duration of stay, hospital charges, in-hospital complications, and in-hospital mortality. Models were adjusted for patient age, sex, race, insurance, socioeconomic status, Elixhauser comorbidity score, and appendix perforation. RESULTS: There were 1,291 (0.38%) patients with human immunodeficiency virus, among which 497 (0.15%) patients had acquired immunodeficiency syndrome. In regression analysis, human immunodeficiency virus alone was not associated with adverse outcomes, while acquired immunodeficiency syndrome alone was associated with longer duration of stay (incidence rate ratio 1.40 [1.37-1.57 95% confidence interval], P < .0001), increased total charges (exponentiated coefficient 1.16 [1.10-1.23 95% confidence interval], P < .0001), and increased risk of postoperative infection (odds ratio 2.12 [1.44-3.13 95% confidence interval], P = .0002). CONCLUSION: Patients with acquired immunodeficiency syndrome who undergo appendectomy for acute appendicitis are subject to longer and more expensive hospital admissions and have greater rates of postoperative infections while patients with human immunodeficiency virus alone are not at risk for adverse outcomes.
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Apendicectomia/métodos , Apendicite/epidemiologia , Apendicite/cirurgia , Infecções por HIV/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Síndrome da Imunodeficiência Adquirida/diagnóstico , Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/cirurgia , Adulto , Idoso , Apendicectomia/efeitos adversos , Apendicite/diagnóstico , Estudos de Casos e Controles , Comorbidade , Bases de Dados Factuais , Feminino , Seguimentos , Infecções por HIV/diagnóstico , Infecções por HIV/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/fisiopatologia , Valores de Referência , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoAssuntos
Bócio/diagnóstico , Doenças do Mediastino/diagnóstico , Biópsia , Diagnóstico Diferencial , Feminino , Bócio/cirurgia , Humanos , Doenças do Mediastino/cirurgia , Pessoa de Meia-Idade , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/patologia , Glândula Tireoide/cirurgia , Tireoidectomia , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center. MATERIALS AND METHODS: Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ(2) and Student's t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant. RESULTS: From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m(2); P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group. CONCLUSION: Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.
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Centros Médicos Acadêmicos , Colecistectomia Laparoscópica/métodos , Doenças da Vesícula Biliar/cirurgia , Robótica/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although cholecystectomy is one of the most common surgical procedures performed in the United States, there is an absence of data on the risks of cholecystectomy in dialysis patients. Our objective was to analyze the outcomes of cholecystectomy in dialysis patients. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we selected all patients who underwent cholecystectomy from 2005 to 2010. Univariate analysis was performed and logistic and linear regression models were used to obtain risk-adjusted outcomes. The main outcomes were morbidity, mortality, and length of stay. RESULTS: Dialysis was associated with a higher risk of 30-day postoperative morbidity (16.1% vs 3.8%, adjusted odds ratio 1.91, 95% confidence interval 1.18 to 3.10), but not mortality. The average length of stay following any cholecystectomy was 4.1 days longer for dialysis patients (5.5 vs 1.4 days, P < .0001). CONCLUSION: Patients on dialysis who undergo cholecystectomy are at a higher risk for postoperative morbidity, but not mortality.
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Colecistectomia , Falência Renal Crônica/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Transfusão de Sangue/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Parada Cardíaca/epidemiologia , Humanos , Falência Renal Crônica/terapia , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Pneumonia/epidemiologia , Reoperação/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Sepse/epidemiologia , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: With each passing year, the number of patients with end-stage renal disease (ESRD) is increasing steadily, but there are limited data on the postoperative outcomes of these patients after appendectomy. METHODS: Using the Nationwide Inpatient Sample, we identified all patients who underwent appendectomy in the United States between 1998 and 2010. We used International Classification of Diseases, 9th Revision, Clinical Modification codes to identify patients with ESRD and to track postoperative complications during hospital admission. Statistical models were controlled for age, sex, race, insurance type, number of Elixhauser comorbidities, year of admission, perforation of the appendix, and operative approach. RESULTS: The study population included 5,712 patients with ESRD, with the remaining 3,615,391 patients serving as reference controls. Patients with ESRD had risk of death that was nearly 5 times greater than controls (odds ratio [OR] 5.68; 95% confidence interval [95% CI] 3.96-8.15; P < .001); this risk was similar for nonperforated (OR 4.97; P < .001) and perforated (5.96; P = .004) appendicitis. The risk of death, however, was greater for open appendectomy (OR 6.65; P < .001) compared with laparoscopic appendectomy (OR 2.50; P = .060). Patients with ESRD also were at an increased risk of mechanical wound complication (OR 1.58; P = .040) and had a mean duration of stay that was 34% greater compared with controls (P < .001). CONCLUSION: Patients with ESRD undergoing appendectomy were at an increased risk of death. These patients also had an increased risk of mechanical wound complications and had a greater duration of hospital stay. Future studies should investigate the specific causes of death among patients with ESRD after appendectomy and optimal management strategies in this subset of patients.
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Apendicectomia/mortalidade , Apendicite/cirurgia , Falência Renal Crônica/complicações , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Apendicectomia/métodos , Apendicite/complicações , Apendicite/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Laparoscopia/mortalidade , Tempo de Internação , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Resultado do Tratamento , Estados UnidosRESUMO
INTRODUCTION: Splenic pseudoaneurysms (SPA) are a rare but serious sequela of blunt traumatic injury to the spleen. Management of adult blunt splenic trauma is well-studied, however, in children, the management is much less well-defined. PRESENTATION OF CASE: A 15 year-old male presented with severe abdominal pain of acute onset after sustaining injury to his left side while playing football. FAST was positive for free fluid in the abdomen. Initial abdomen CT demonstrated a grade III/IV left splenic laceration with moderate to large hemoperitoneum with no active extravasation or injury to the splenic vessels noted. A follow-up CT angiography of the abdomen demonstrated a splenic hypervascular structure suspicious for a small pseudoaneurysm. Splenic arteriogram which demonstrated multiple pseudoaneurysms arising from the second order splenic artery branches which was angioembolized and treated. DISCUSSION & CONCLUSION: Questions still remain regarding the timing of repeat imaging for diagnosis of SPA following non-operative blunt splenic trauma, which patients should be imaged, and how to manage SPA upon diagnosis. More clinical study and basic science research is warranted to study the disease process of SPA in pediatric patient. We believe that our proposed management algorithm timely detect formation of delayed SPA formation and addresses the possible fatal disease course of pediatric SPA.