Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer.

BACKGROUND: We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017. METHODS: Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017. RESULTS: A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10 days vs. 13 days, mean difference: 3 days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159 min vs. 137 min, P < 0.01). CONCLUSION: A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.

Unplanned readmission after outpatient laparoscopic cholecystectomy.

BACKGROUND: Readmission after surgery has been considered as a measure of quality of hospital and surgical care. This study aims to investigate unplanned readmission after laparoscopic cholecystectomy. METHODS: The NSQIP database was used to investigate 30 days unplanned readmission after laparoscopic cholecystectomy. Multivariate analysis was used to identify predictors of readmission. RESULTS: We found a total of 117,248 patients who underwent outpatient laparoscopic cholecystectomy during 2014-2016. Of these 3315 (2.8%) had unplanned readmission. Overall, 90% of readmitted patients were discharged after one day of hospitalization. Pain (14.07%) followed by unspecified symptoms including fever, nausea, vomiting, ileus was the most common reason for readmission. After adjustment, factors such as renal failure on dialysis (AOR: 2.26, P < 0.01), discharge to a facility (AOR: 1.93, P < 0.01), and steroid use for chronic condition (AOR: 1.51, P < 0.01), were associated with unplanned readmission. CONCLUSION: Overall, 2.8% of the patients undergoing outpatient laparoscopic cholecystectomy are readmitted to the hospital. Most of such patients are discharged after one day of hospitalization. Unspecified symptoms such as pain and vomiting were the most common reasons for readmission. Readmission strongly influences patients' comorbid factors and it is not a reliable measurement of quality of hospital and surgical care.

Kidney Autotransplantation: Between the Past and the Future.

PURPOSE OF REVIEW: The practice of kidney autotransplantation (KAT) has become an increasingly favorable approach in the treatment of certain renovascular, ureteral, and malignant pathologies. Current KAT literature describes conventional open procedures, which are associated with substantial risks. We sought to compare previously reported outcomes, evaluate common surgical indications, and assess associated risks and benefits of current KAT methods. A thorough evaluation and review of the literature was performed with the keywords "autologous transplantation" and "kidney." RECENT FINDINGS: Early outcomes of robotic KAT are encouraging and have been associated with fewer complications and shorter hospital stay, but require robotic technique proficiency. KAT is an important method to manage selected complex urological pathologies. Robotic KAT is promising. Nevertheless, future studies should utilize larger patient cohorts to better assess the risks and benefits of KAT and to further validate this approach.

A nationwide analysis of re-exploration after liver transplant.

BACKGROUND: A retrospective review to investigate rate and outcomes of re-exploration following liver transplantation in the United States. METHODS: The NIS database was used to examine outcomes of patients who underwent re-exploration following liver transplantation from 2002 to 2012. Multivariate regression analysis was performed to compare outcomes of patients with and without reoperation. RESULTS: We sampled a total of 12,075 patients who underwent liver transplantation. Of these, 1505 (12.5%) had re-exploration during the same hospitalization. Hemorrhagic (67.9%) and biliary tract anastomosis complication (14.8%) were the most common reasons for reoperation. Patients with reoperation had a significantly higher mortality than those who did not (11.6% vs. 3.8%, AOR: 3.01, P < 0.01). Preoperative coagulopathy (AOR: 1.71, P < 0.01) and renal failure (AOR: 1.57, P < 0.01) were associated with hemorrhagic complications. Peripheral vascular disorders (AOR: 2.15, P < 0.01) and coagulopathy (AOR: 1.32, P < 0.01) were significantly associated with vascular complications. Risk of wound disruption was significantly higher in patients with chronic pulmonary disease (AOR: 1.50, P < 0.01). CONCLUSION: Re-exploration after liver transplantation is relatively common (12.5%), with hemorrhagic complication as the most common reason for reoperation. Preoperative coagulation disorders significantly increase hemorrhagic and vascular complications. Further clinical trails should investigate prophylactic strategies in high risk patients to prevent unplanned reoperation.

Risk factors and outcomes of postoperative ischemic colitis in contemporary open and endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes. RESULTS: We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P < .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P < .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P = .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P < .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P < .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P = .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P = .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P = .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P = .04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P = .43). CONCLUSIONS: Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality.

Comparison of open, laparoscopic, and robotic approaches for total abdominal colectomy.

BACKGROUND: The utilization of minimally invasive surgery is increasing in colorectal surgery. We sought to compare the outcomes of patients who underwent elective open, laparoscopic, and robotic total abdominal colectomy. METHODS: The NIS database was used to examine the clinical data of patients who underwent an elective total colectomy procedure during 2009-2012. Multivariate regression analysis was performed to compare the three surgical approaches. RESULTS: We sampled a total of 26,721 patients who underwent elective total colectomy. Of these, 16,780 (62.8 %) had an open operation, while 9934 (37.2 %) had a minimally invasive approach (9614 laparoscopic surgery, and 326 robotic surgery). The most common indication for an operation was ulcerative colitis (31 %). Patients who underwent open surgery had significantly higher mortality and morbidity compared to laparoscopic (AOR 2.48, 1.30, P < 0.01) and robotic approaches (AOR 1.04, 1.30, P < 0.01 and P = 0.04, respectively). There was no significant difference in mortality and morbidity between the laparoscopic and robotic approaches (AOR 0.96, 1.03, P = 0.10, P = 0.78). However, conversion rate of laparoscopic surgery to open was significantly higher than that of robotic approach (13.3 vs. 1.5 %, P < 0.01). Patients who underwent laparoscopic surgery had significantly lower total hospital charges compared to patients who underwent open surgery (mean difference = $21,489, P < 0.01). Also, total hospital charges for a robotic approach were significantly higher than for a laparoscopic approach (mean difference = $15,595, P < 0.01). CONCLUSION: Minimally invasive approaches to total colectomy are safe, with the advantage of lower mortality and morbidity compared to an open approach. Although there was no significant difference in the morbidity between minimally invasive approaches, robotic surgery had a significantly lower conversion rate compared to laparoscopic approach. Total hospital charges are significantly higher in robotic surgery compared to laparoscopic approach.

Risk factors for prolonged ileus following colon surgery.

BACKGROUND: Prolonged ileus is one of the most common postoperative complications after colorectal surgery. We sought to investigate the predictors of prolonged ileus following elective colon resections procedures. METHODS: The national participant user files of NSQIP databases were utilized to examine the clinical outcomes of patients undergoing elective colon resection during 2012-2013. Multivariate regression analysis was performed to investigate predictors of prolonged ileus. Prolonged ileus was defined as no return of bowel function in 7 days. RESULTS: We sampled a total of 27,560 patients who underwent colon resections; of these, 3497 (12.7%) patients had prolonged ileus. Patients with ileocolonic anastomosis (ICA) had a significantly higher rate of prolonged ileus compared to patients with colorectal anastomosis (CRA) (15 vs. 11.5%, AOR 1.25, P < 0.01). Prolonged ileus was significantly associated with intra-abdominal infections (13 vs. 2.8%, AOR 2.56, P < 0.01) and anastomotic leakage (12 vs. 2.4%, AOR 2.50, P < 0.01). Factors such as preoperative sepsis (AOR 1.63, P < 0.01), disseminated cancer (AOR 1.24, P = 0.01), and chronic obstructive pulmonary disease (AOR 1.27, P = 0.02) were associated with an increased risk of prolonged ileus, whereas oral antibiotic bowel preparation (AOR 0.77, P < 0.01) and laparoscopic surgery (AOR 0.51, P < 0.01) are associated with decreased prolonged ileus risk. CONCLUSIONS: Prolonged ileus is a common condition following colon resection, with an incidence of 12.7%. Among colon surgeries, colectomy with ICA resulted in the highest rate of postoperative prolonged ileus. Prolonged ileus is positively associated with anastomotic leak and intra-abdominal infections; thus, a high index of suspicion must be had in all patients with prolonged postoperative ileus.

Trends in colorectal cancer admissions and stage at presentation: impact of screening.

BACKGROUND: Colorectal cancer (CRC) incidence is rising among patients under age 50. As such, we set out to determine the proportion of CRC-related hospital admissions and distribution of colon cancer by stage in different age groups. METHODS: The NIS database for 2002-2012 was used to investigate trends of colorectal cancer resection by age, and the ACS NSQIP database for 2012-2013 was used to investigate contemporary stage at diagnosis for colon cancer in different age groups. RESULTS: A total of 1,198,421 patients were admitted to a hospital with a diagnosis of CRC and captured by the NIS database. Although the number of hospitalized CRC patients decreased from 2002 to 2012, the observed decrease was predominant in patients older than 65 years (P < 0.01) and in colon cancer compared to rectal cancer patients (P < 0.01). The proportion of patients younger than 65 years increased from 32.8 % in 2002 to 41.1 % in 2012, and the proportion of patients under age 50 increased from 9 to 12 %. In the NSQIP database, the age <50 group also had a significantly higher proportion of advanced disease (stage III/IV) compared to patients age 50 and older (62.3 vs. 47.5 %, P < 0.01). In 2012, it was observed that most patients with rectal cancer were younger than 65 years (55.8 %). CONCLUSION: There was a steady decrease in the number of hospitalized patients with colorectal cancer during the last decade, primarily attributable to a decrease in the older than 65 years age patients and colon cancer patients. The proportion of hospitalized patients age <50 is rising. In addition, patients younger than 50 years were more likely to have advanced disease compared to older patients.

Retrorectal Tumors: A Comprehensive Literature Review.

IMPORTANCE: Retrorectal tumors are rare lesions that comprise a multitude of histologic types. Reports are limited to small single-institution case series, and recommendations on the ideal surgical approaches are lacking. OBJECTIVE: The purpose of the study was to provide a comprehensive review of the epidemiology, pathologic subtypes, surgical approaches, and clinical outcomes of retrorectal tumors. EVIDENCE REVIEW: We conducted a review of the literature using PubMed and searched the reference lists of published studies. RESULTS: A total of 341 studies comprising 1708 patients were included. Overall, 68 % of patients were female. The mean age was 44.6 ± 13.7 years. Of all patients, 1194 (70 %) had benign lesions, and 514 patients (30 %) had malignant tumors. Congenital tumors (60.5 %) were the most frequent histologic type. Other pathologic types were neurogenic tumors (14.8 %), osseous tumors (3.1 %), inflammatory tumors (2.6 %), and miscellaneous tumors (19.1 %). Biopsy was performed in 27 % of the patients. Of these patients, incorrect diagnoses occurred in 44 %. An anterior surgical approach (AA) was performed in 299 patients (35 %); a posterior approach (PA) was performed in 443 (52 %), and a combined approach (CA) was performed in 119 patients (14 %). The mean length of stay (LOS) of PA was 7 ± 5 days compared to 8 ± 7 days for AA and 11 ± 7 days for CA (p < 0.05). The overall morbidity rate was 13.2 %: 19.3 % associated with anterior approach, 7.2 % associated with posterior approach, and 24.7 % after a combined approach (p < 0.05). Overall postoperative recurrence rate was 21.6 %; 6.7 % after an anterior approach, 26.6 % after a posterior approach, and 28.6 % after a combined approach (p < 0.05). A minimally invasive approach (MIS) was employed in 83 patients. MIS provided shorter hospital stays than open surgery (4 ± 2 vs. 9 ± 7 days; p < 0.05). Differences in complication rate were 19.8 % in MIS and 12.2 % in open surgery and not statistically significant. CONCLUSIONS AND RELEVANCE: Retrorectal tumors are most commonly benign in etiology, of a congenital nature, and have a female predominance. Complete surgical resection is the cornerstone of retrorectal tumor management. A minimal access surgery approach, when feasible, appears to be a safe option for the management of retrorectal tumors, with shorter operative time and length of stay.

Post-Hospital Discharge Venous Thromboembolism in Colorectal Surgery.

BACKGROUND: There are limited data regarding the criteria for prophylactic treatment of venous thromboembolism (VTE) after hospital discharge. We sought to identify risk factors of post-hospital discharge VTE events following colorectal surgery. METHODS: The NSQIP database was utilized to examine patients developed VTE after hospital discharge following colorectal surgery during 2005-2013. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE after discharge. RESULTS: We evaluated a total of 219,477 patients underwent colorectal resections. The overall incidence of VTE was 2.1 % (4556). 33.8 % (1541) of all VTE events occurred after hospital discharge. The length of postoperative hospitalization had a strong association with post-discharge VTE, with the highest risk in patients who were hospitalized for more than 1 week after operation (AOR 9.08, P < 0.01). Other factors associated with post-discharge VTE included chronic steroid use (AOR 1.81, P < 0.01), stage 4 colorectal cancer (AOR 1.40, P = 0.03), obesity (AOR 1.37, P < 0.01), age >70 (AOR 1.21, P = 0.04), and open surgery (AOR 1.36, P < 0.01). Patients who were hospitalized for more than 1 week after an open colorectal resections had a 12 times higher risk of post-discharge VTE event compared to patients hospitalized less than 4 days after a laparoscopic resection (AOR 12.34, P < 0.01). CONCLUSIONS: VTE is uncommon following colorectal resections; however, a significant proportion occurs after patients are discharged from the hospital (33.8 %). The length of postoperative hospitalization appears to have a strong association with post-discharge VTE. High-risk patients may benefit from continued VTE prophylaxis after discharge.

Outcomes of Open, Laparoscopic, and Robotic Abdominoperineal Resections in Patients With Rectal Cancer.

BACKGROUND: There are limited available data comparing open, laparoscopic, and robotic approaches for rectal cancer surgery. OBJECTIVE: We sought to investigate outcomes of different surgical approaches to abdominoperineal resection in patients with rectal cancer. DESIGN: The nationwide inpatient sample database was used to examine the clinical data of patients with rectal cancer who underwent elective abdominoperineal resection between 2009 and 2012 in the United States. Multivariate regression analysis was performed to compare outcomes of different surgical approaches. SETTINGS: A retrospective review according to the national inpatient sample database was designed. PATIENTS: We included patients with rectal cancer who underwent elective abdominoperineal resection between 2009 and 2012. MAIN OUTCOME MEASURES: Outcomes of different surgical approaches to abdominoperineal resection were investigated. RESULTS: We sampled 18,359 patients with rectal cancer who underwent elective abdominoperineal resections. Of these, 69.5% had open surgery, 25.8% had laparoscopic surgery, and 4.7% had robotic surgery. The rate of robotic procedures increased >4-fold, from 2.1% to 8.1%, from 2009 to 2012. The conversion rate in robotic surgery was significantly lower compared with laparoscopic surgery (5.7% vs 13.4%; p < 0.01). After risk adjustment, patients who underwent laparoscopic and robotic approaches had lower morbidity risks compared with those who underwent the open approach (adjusted OR = 0.77 (95% CI, 0.65-0.92), 0.57 (95% CI, 0.40-0.80); p < 0. 01). There were no significant differences in the morbidity rate of patients who underwent laparoscopic or robotic approaches (adjusted OR = 0.79 (95% CI, 0.55-1.14); p = 0.21). However, patients who underwent the robotic approach had significantly higher total hospital charges compared with those who underwent the laparoscopic approach (mean difference, $24,890; p < 0.01). LIMITATIONS: We could not adjust the results with some important factors, such as the tumor stage and BMI. CONCLUSIONS: The use of robotic and laparoscopic approaches to abdominoperineal resection have increased between 2009 and 2012. Both minimally invasive approaches decrease morbidity rates of patients undergoing abdominoperineal resection. The robotic approach has a significantly lower conversion rate compared with the laparoscopic approach. However, it had significantly higher total hospital charges compared with the laparoscopic approach.

Variations in Laparoscopic Colectomy Utilization in the United States.

BACKGROUND: Recent published articles reported a wide geographic variation in the utilization of laparoscopic colectomy in the United States. OBJECTIVES: This study aimed to report the current rates of laparoscopic colon resection in different types of hospitals in the United States. DESIGN: The Nationwide Inpatients Sample database was used to examine the clinical data of patients undergoing elective colon resection for the diagnosis of colon cancer or diverticular disease from 2009 to 2012. SETTING: Multivariate regression analysis was performed to compare different hospital types and regions regarding the utilization of laparoscopy. PATIENTS: Patients undergoing elective colon resection for the diagnosis of colon cancer or diverticular disease from 2009 to 2012 were selected. MAIN OUTCOME MEASURES: The primary outcome measured was the rates of laparoscopic colon resection in different types of hospitals. RESULTS: We sampled a total of 309,816 patients who underwent elective colon resection. Of these, 171,666 (55.4%) had a laparoscopic operation. The utilization of a laparoscopic approach increased from 51.3% in 2009 to 59.3% in 2012. The increased utilization of a laparoscopic approach was seen in both urban (53.6% vs 61.6%) and rural hospitals (33.4% vs 42.3%), for colon cancer (45% vs 53.5%), and diverticular disease (61.9% vs 68.2%). The conversion rate to open surgery for diverticular disease was significantly higher than for colon cancer (adjusted odds ratio (AOR), 1.23; p < 0.01). After adjustment, urban hospitals (AOR, 2.13; p < 0.01), teaching hospitals (AOR, 1.13; p < 0.01), and large hospitals (AOR, 1.33; p < 0.01) had a greater utilization of laparoscopic surgery. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Although we have finally reached the point where a majority of patients undergoing an elective colectomy for diverticular disease and colon cancer receive a laparoscopic operation, there is wide variation in the implementation of laparoscopic surgery in colon resection in the United States. The utilization of a laparoscopic approach has associations with hospital factors such as size, teaching status of the hospital, and geographic location (urban vs rural).

Surgical site infection impact of pelvic exenteration procedure.

BACKGROUND: We sought to investigate morbidity and infectious complications following pelvic exenteration (PEx) and compare infectious complications of patients undergoing PEx and conventional rectal resections. METHODS: The NSQIP database was utilized to examine the clinical data of patients undergoing elective rectal resections during 2005-2013. Multivariate regression analysis was used to compare postoperative complications of patients who underwent PEx and proctectomy procedure. RESULTS: We sampled a total of 7,950 patients who underwent rectal resection. Of these, 303 (3.8%) patients underwent pelvic exenteration. Mortality, morbidity, and infectious complications of patients who underwent pelvic exenteration were 1.7%, 65.7%, and 42.6%, respectively. Patients who underwent PEx had a significantly higher rate of morbidity (AOR: 2.01, P < 0.01), overall infectious complications (AOR: 1.49, P < 0.01), hemorrhagic complications (AOR: 3.36, P < 0.01), and surgical site infections (SSI) (AOR: 1.23, P = 0.04) compared to patients who underwent proctectomy. Return to operation room (AOR: 4.99, P < 0.01), obesity (AOR: 1.43, P < 0.01), disseminated cancer (AOR: 1.30, P = 0.01) were significantly associated with SSI complications. CONCLUSION: Postoperative morbidity and infectious complication are significantly higher after PEx procedure. Return to operation room, obesity, and disseminated cancer are strongly associated with surgical site infections complications in rectal surgery. Specific consideration to infectious complications is recommended for these patients.

Wound Disruption Following Colorectal Operations.

OBJECTIVES: Postoperative wound disruption is associated with high morbidity and mortality. We sought to identify the risk factors and outcomes of wound disruption following colorectal resection. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to examine the clinical data of patients who underwent colorectal resection from 2005 to 2013. Multivariate regression analysis was performed to identify risk factors of wound disruption. RESULTS: We sampled a total of 164,297 patients who underwent colorectal resection. Of these, 2073 (1.3 %) had wound disruption. Patients with wound disruption had significantly higher mortality (5.1 vs. 1.9 %, AOR: 1.46, P = 0.01). The highest risk of wound disruption was seen in patients with wound infection (4.8 vs. 0.9 %, AOR: 4.11, P < 0.01). A number of factors are associated with wound disruption such as chronic steroid use (AOR: 1.71, P < 0.01), smoking (AOR: 1.60, P < 0.01), obesity (AOR: 1.57, P < 0.01), operation length more than 3 h (AOR: 1.56, P < 0.01), severe Chronic Obstructive Pulmonary Disease (COPD) (AOR: 1.36, P < 0.01), urgent/emergent admission (AOR: 1.31, P = 0.01), and serum Albumin Level <3 g/dL (AOR: 1.27, P < 0.01). Laparoscopic surgery had significantly lower risk of wound disruption compared to open surgery (AOR: 0.61, P < 0.01). CONCLUSION: Wound disruption occurs in 1.3 % of colorectal resections, and it correlates with mortality of patients. Wound infection is the strongest predictor of wound disruption. Chronic steroid use, obesity, severe COPD, prolonged operation, non-elective admission, and serum albumin level are strongly associated with wound disruption. Utilization of the laparoscopic approach may decrease the risk of wound disruption when possible.

Risk factors for conversion of laparoscopic colorectal surgery to open surgery: does conversion worsen outcome?

INTRODUCTION: The utilization of laparoscopy in colorectal surgery is increasing. However, conversion to open surgery remains relatively high. OBJECTIVE: We evaluated (1) conversion rates in laparoscopic colorectal surgery; (2) the outcomes of converted cases compared with successful laparoscopic and open colorectal operations; (3) predictive risk factors of conversion of laparoscopic colorectal surgery to open surgery. METHODS: Using the National Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2009 to 2010. Multivariate regression analysis was performed to identify factors predictive for conversion of laparoscopic to open operation. RESULTS: A total of 207,311 patients underwent intended laparoscopic colorectal resection during this period. The conversion rate was 16.6 %. Considering resection type and pathology, the highest conversion rates were observed in proctectomy (31.4 %) and Crohn's disease (20.2 %). Using multivariate regression analysis, Crohn's disease (adjusted odds ratio [AOR], 2.80), prior abdominal surgery (AOR, 2.45), proctectomy (AOR, 2.42), malignant pathology (AOR, 1.90), emergent surgery (AOR, 1.82), obesity (AOR, 1.63), and ulcerative colitis (AOR, 1.60) significantly impacted the risk of conversion. Compared with patients who were successfully completed laparoscopically, converted patients had a significantly higher complication rate (laparoscopic: 23 %; vs. converted: 35.2 % vs. open: 35.3 %), a higher in-hospital mortality rate (laparoscopic: 0.5 %; vs. converted: 0.6 %; vs. open: 1.7 %) and a longer mean hospital stay (laparoscopic: 5.4 days; vs. converted: 8.1 days; vs. open: 8.4 days); however, converted patients had better outcomes compared with the open group. CONCLUSIONS: The conversion rate in colorectal surgery was 16.6 %. Converted patients had significantly higher rates of morbidity and mortality compared to successfully completed laparoscopic cases, although lower than open cases. Crohn's disease, prior abdominal surgery, and proctectomy are the strongest predictors for conversion of laparoscopic to open in colorectal operations.

The Economic Effects on Acute Care Surgery in a New York City Public Hospital During the COVID Pandemic.

BACKGROUND: Since the start of the COVID-19 pandemic, less acute care surgical procedures have been performed and consequently hospitals have experienced significant revenue loss. We aim to investigate these procedures performed before and after the start of the COVID-19 pandemic, as well as their effect on the economy. METHODS: This is a retrospective analysis of patients who underwent cholecystectomies and appendectomies during March-May 2019 compared to the same time period in 2020 using Chi-square and t-tests. RESULTS: There were 345 patients who presented with appendicitis or cholecystitis to Elmhurst Hospital Center during the March-May 2019 and 2020 time period. There were three times as many total operations, or about 75%, in 2019 (261) compared to 2020 (84). There was a decrease in the number of admissions from 2019 to 2020 for both acute cholecystitis (149 vs 43, respectively) and acute appendicitis (112 vs 41, respectively). The largest decrease in the number of admissions in 2020 compared to 2019 was observed in April 2020 (98 vs 9, P < .01) followed by May [69 vs 20, P < .01], and March [94 vs 55, P < .01]. Corresponding to the decrease in operative patterns was a noticeable six-time reduction in revenue for the procedures in 2019 ($187,283) compared to 2020 ($30,415). CONCLUSION: We observed almost a triple reduction in the number of cholecystitis and appendicitis procedures performed during the 2020 pandemic surge as compared to the 2019 pre-pandemic data. Elmhurst hospital also experienced four times the loss of revenue during the same time period.

Minimally Invasive Surgical Approach to Toxic Colitis.

BACKGROUND: We aimed to compare outcomes of surgical treatments of toxic colitis (infectious/inflammatory/ischemic) by the extent of colectomy (partial vs total colectomy) and different surgical approaches (minimally invasive surgery (MIS) vs open). METHODS: Multivariate analysis using logistic regression was used to investigate outcomes of patients with toxic colitis who underwent emergent colectomy during 2012-2019 by surgical approach and the extent of resection using NSQIP database. RESULTS: Overall, 2,104 adult patients underwent emergent colectomy for toxic colitis within NSQIP database during 2012-2019. Overall, 1,578 (75.4%) underwent total colectomy with colostomy, 486 (23.2%) underwent partial colectomy with colostomy, and 28 (1.3%) underwent partial colectomy with anastomosis. Overall, 198 (9.4%) of procedures were minimally invasive (MIS) with a 40.1% conversion rate to open. Thirty days mortality and morbidity of the patients were 31 and 86%, respectively. There was no significant difference in mortality of partial colectomy without anastomosis compared to total colectomy (P = .86) and partial colectomy with anastomosis (P = .64). Anastomosis was associated with 32.3% anastomosis leakage and 17.9% reoperation. MIS approach was associated with significant decrease in mortality (8.6 vs 33.3%, AOR: .35, P < .01) and morbidity (62.9 vs 87.8%, AOR: .49, P < .01) of patients. CONCLUSION: Patients with toxic colitis undergoing surgical treatment have high mortality and morbidity. An MIS approach when possible is significantly associated with decreased morbidity and mortality of patients. There was no significant difference in outcomes seen when extending the resection in multivariate analysis. Anastomosis is associated with a high anastomosis leakage and need for reoperation risk.

Outcome of bile leakage following liver resection with hepaticojejunostomy for liver cancer.

We aimed to investigate contemporary management and outcomes of bile leakage in patients who underwent hepatectomy with hepaticojejunostomy for liver malignancy. The NSQIP database was used to study clinical data of patients who underwent a hepatectomy with hepaticojejunostomy for a primary hepatobiliary cancer and developed bile leakage between 1/2014 and 12/2017. Multivariate regression analysis was performed to investigate outcomes. Five hundred patients underwent a hepatectomy with hepaticojejunostomy for a malignant primary hepatobiliary cancer (41% intrahepatic cholangiocarcinoma, 38.2% hilar cholangiocarcinoma, 9.8% hepatocellular carcinoma, 6% gallbladder cancer, and 5% others). The rate of bile leakage was 33.4%. Most patients (90.4%) did not require re-exploration. In 77 of 157 patients (49.1%), bile leakages were contained with intraoperatively placed drain(s) and no additional surgical intervention was required. A total of 71 patients (42.5%)-including 64 patients with intraoperative drains-required interventional radiology (IR)-guided drainage, with a 88.7% success rate. A total of 16 patients (9.6%) required re-exploration to control the leakage, with 8 of them having undergone failed IR-drainage. When running multivariate analysis, post-hepatectomy liver failure (AOR: 158.26, P < 0.01), preoperative sepsis (AOR: 36.24, P = 0.03), and smoking (AOR: 14.07, P = 0.03) were significantly associated with mortality of patients. Biliary leakage is relatively common following hepatectomy with hepaticojejunostomy for liver malignancy (33.4%), but most patients (90.4%) do not require re-exploration. Intraoperatively placed drains successfully controlled 46.7% of bile leakages. IR-guided drain placement had a 88.7% success rate for adequate leak control.

Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis.

BACKGROUND: We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality. METHODS: The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach. RESULTS: We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0). CONCLUSION: The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.

Hospital-Acquired Conditions after Liver Transplantation.

Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002-2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter-associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter-associated infection is the most common HAC after liver transplantation.