Surgical Outcomes and Utilization of Laparoscopic Versus Robotic Techniques for Elective Colectomy in Asian American and Native Hawaiian-Pacific Islanders (AAPI) Diagnosed With Colon Cancer.

INTRODUCTION: Asian American and Native Hawaiian-Pacific Islanders (AAPI) are the fastest growing racial-ethnic group, with 18.9 million people in 2019, and is predicted to rise to 46 million by 2060. Colorectal cancer (CRC) is the most common cancer in AAPI men and the third most common in women. Treatment techniques like laparoscopic colectomy (LC) emerged as the standard of care for CRC resections; however, new robotic technologies can be advantageous. Few studies have compared clinical outcomes across minimally invasive approaches for AAPI patients with CRC. This study compares utilization and clinical outcomes of LC versus robotic colectomies (RCs) in AAPI patients. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for elective RC and LC in AAPI patients from 2012 to 2020. Outcomes included unplanned conversion to open, operative time, complications, 30-d mortality, and length of stay. Multivariable logistic regression analyses assessed the association between outcomes and the operative approach. RESULTS: Between 2012 and 2020, 83,841 patients underwent elective LC or RC. Four thousand six hundred fifty-eight AAPI patients underwent 3817 (82%) LCs and 841 (18%) RCs. In 2012, all procedures were performed laparoscopically; by 2020, 27% were robotic. Mean operative time was shorter in LC (192 versus 249 min, P < 0.001). On multivariable logistic regression, there was no difference in infection (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.59-1.12), anastomotic leak (OR 0.97, 95% CI 0.59-1.61), or death (OR 0.9, 95% CI 0.31-2.61). Length of stay was shorter for RC (-0.44 d, 95% CI -0.71 to -0.18 d). CONCLUSIONS: Overall, AAPI postoperative outcomes are similar between LC and RC. Future studies that evaluate costs and resource utilization can assist hospitals in determining whether implementing robotic-assisted technologies in their hospitals and communities will be appropriate.

Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database.

BACKGROUND: Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. METHODS: We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. RESULTS: We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). CONCLUSIONS: Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.

Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches.

BACKGROUND: We sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement. METHODS: We queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression. RESULTS: We identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P â€‹< â€‹0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03-1.08, P â€‹= â€‹0.005) than their White LC counterparts and RC patients. CONCLUSIONS: Robotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.

Glycemic control and infections in patients with diabetes undergoing noncardiac surgery.

OBJECTIVE: Examine the relationship between perioperative glucose control and postoperative infections in a nationwide sample of diabetic patients undergoing a wide variety of surgical procedures. SUMMARY OF BACKGROUND DATA: Perioperative glucose control has been linked to postoperative infections after selected surgical procedures. METHODS: Retrospective analysis of surgical outcomes data from 1999 to 2004 on 55,408 patients with diabetes undergoing a variety of noncardiac operations contained in the Veterans Heath Administration National Surgical Quality Improvement Program database, supplemented with the Veterans Heath Administration Decision Support Services hemoglobin A1c (HbA(1c)) and serum glucose data. Multivariate Poisson regression model of postoperative infection including demographics, comorbidities, functional status, preoperative laboratories, surgical data, and glucose control (diabetes medications, serum glucose, HbA(1c), mean serum glucose within 24 hours after surgery). RESULTS: The most common procedures were herniorrhaphy (10%), carotid endarterectomy (6.6%), and open colectomy (5.6%). Mean (SD) preoperative HbA1c concentration was 7.9% (2.3); 51% of patients had preoperative serum glucose concentrations more than 150 mg/dL; and 72% of patients had a mean 24 hour postoperative glucose concentration at least 150 mg/dL. The overall postoperative infection rate was 8.0%. Higher rates of postoperative infection were associated with mean 24 hour postoperative serum glucose concentrations of 150 to 250 mg/dL (incidence rate ratio 1.22, 95% confidence interval, 1.04-1.43; P = 0.01) and more than 250 mg/dL (incidence rate ratio: 1.43; 95% confidence interval, 1.19-1.71; P < 0.001). Preoperative HbA1c and glucose concentrations were not associated with increased infection rates. CONCLUSIONS: In a large nationwide sample of diabetic patients undergoing a variety of noncardiac surgical procedures, glucose control in the first 24 hours after surgery was poor, and mean serum glucose concentrations of 150 mg/dL and higher during this time period were associated with increased rates of postoperative infectious complications.

The duration of postoperative acute kidney injury is an additional parameter predicting long-term survival in diabetic veterans.

Acute kidney injury (AKI) is primarily defined and staged according to the magnitude of the rise in serum creatinine. Here we sought to determine if the duration of AKI adds additional prognostic information above that from the magnitude of injury alone. We prospectively studied 35,302 diabetic patients from 123 Veterans Affairs Medical Centers undergoing their first noncardiac surgery. The main outcome was long-term mortality in those who survived the index hospitalization. AKI was stratified by magnitude according to AKI Network stages and by the duration (short (less than 2 days), medium (3-6 days) or long (7 days or more)). Overall, 17.8% of patients experienced at least stage 1 AKI or greater following surgery. Both the magnitude and duration of AKI were significantly associated with long-term survival in a dose-dependent manner. Within each stage, longer duration of AKI was significantly associated with a graded higher rate of mortality. However, within each of the duration categories, the stage was not associated with mortality. When considered separately in multivariate analyses, both a higher stage and duration were independently associated with increased risk of long-term mortality. Hence, the duration of AKI adds additional information to predict long-term mortality.

Long-term glycemic control and postoperative infectious complications.

HYPOTHESIS: Good preoperative glycemic control (hemoglobin A(1c) [HbA(1c)] levels <7%) is associated with decreased postoperative infections. DESIGN: Retrospective observational study using Veterans Affairs National Surgical Quality Improvement Program data from the Veterans Affairs Connecticut Healthcare System from January 1, 2000, through September 30, 2003. SETTING: Veterans Affairs Connecticut Healthcare System, a tertiary referral center and major university teaching site. PATIENTS: Six hundred forty-seven diabetic patients underwent major noncardiac surgery during the study period; 139 were excluded because the HbA(1c) levels were more than 180 days prior to surgery; 19 were excluded for other reasons; 490 diabetic patients were analyzed. The study patients were predominantly nonblack men with a median age of 71 years. MAIN OUTCOME MEASURES: Primary outcomes were infectious complications, including pneumonia, wound infection, urinary tract infection, or sepsis. Bivariate analysis was used first to determine the association of each independent variable (age, race, diabetic treatment, American Society of Anesthesiologists classification, Activities of Daily Living assessment, elective vs emergent procedure, wound classification, operation length, and HbA(1c) levels) with outcome. Factors significant at P<.05 were used in a multivariable logistic regression model. RESULTS: In the multivariable model, age, American Society of Anesthesiologists class, operation length, wound class, and HbA(1c) levels were significantly associated with postoperative infections. Emergency/urgent cases and dependence in Activities of Daily Living were significant in bivariate analysis but failed to reach statistical significance in the multivariable model. An HbA(1c) level of less than 7% was significantly associated with decreased infectious complications with an adjusted odds ratio of 2.13 (95% confidence interval, 1.23-3.70) and a P value of .007. CONCLUSION: Good preoperative glycemic control (HbA(1c) levels <7%) is associated with a decrease in infectious complications across a variety of surgical procedures.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

UNLABELLED: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence. PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators.

IMPORTANCE: Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized. OBJECTIVE: To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level. MAIN OUTCOMES AND MEASURES: All-cause 30-day postoperative mortality. RESULTS: The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/µL or more, 16.3% with 50/µL to 199/µL, and 3.7% with less than 50/µL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/µL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/µL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/µL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/µL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality. CONCLUSIONS AND RELEVANCE: Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

Restructuring care for older adults undergoing surgery: preliminary data from the Co-Management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) model of care.

Surgery is common in older adults, so geriatric and surgical providers need to develop expertise in the care of older adults undergoing surgery. The Co-management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) program is a clinical and educational collaboration between geriatrics and several surgical specialties at Veterans Affairs Health Care Connecticut. Individuals in CO-OPERATE are co-managed during the pre-, peri-, and postoperative periods. General surgery, urology, vascular surgery, orthopedics, cardiothoracic surgery and neurosurgery all participate in the program, with geriatrics expertise provided by a geriatrician, geriatric nurse practitioner and a geriatric clinical pharmacist. In the initial 3 years, there were 211 CO-OPERATE participants; 31% were evaluated preoperatively, and 62% of the individuals seen preoperatively were seen in clinic. There was a median of three recommendations per consultation. At discharge, 56% returned to the community. Individuals seen preoperatively were more likely to return to the community (63%) than those seen after surgery (50%, P = .10). Geriatrics co-management with a variety of surgical specialties is feasible and may be associated with higher rates of discharge back to the community.

Disparities in rates of spine surgery for degenerative spine disease between HIV-infected and uninfected veterans.

STUDY DESIGN: Retrospective analysis of nationwide Veterans Health Administration clinical and administrative data. OBJECTIVE: Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease. SUMMARY OF BACKGROUND DATA: Combination antiretroviral therapy has prolonged survival in HIV-infected patients, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery. METHODS: We studied all HIV-infected patients under care in the Veterans Health Administration from 1996 to 2008 (n = 40,038) and uninfected comparator patients (n = 79,039) matched on age, sex, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease, defined by International Classification of Diseases, Ninth Revision procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, combination antiretroviral therapy, and laboratory values). RESULTS: Two hundred twenty-eight HIV-infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1000 patient-years). The most common procedures were spinal decompression (50%) and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%) and cervical (40%) spine. Adjusted rates of surgery were lower for HIV-infected patients (0.86 per 1000 patient-years of follow-up) than for uninfected patients (1.41 per 1000 patient-years; incidence rate ratio 0.61, 95% confidence interval: 0.51-0.74, P < 0.001). Among HIV-infected patients, there was a trend toward lower rates of spine surgery in patients with detectable viral load levels (incidence rate ratio 0.76, 95% confidence interval: 0.55-1.05, P = 0.099). CONCLUSION: In the Veterans Health Administration, HIV-infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of nonspine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

The esophageal Doppler monitor in mechanically ventilated surgical patients: does it work?

BACKGROUND: Assessment of cardiac volumes and cardiac output (CO) using a pulmonary artery catheter (PAC) in mechanically ventilated patients can be inconsistent and difficult. The esophageal Doppler monitor (EDM) is emerging as a potential alternative to the PAC. This prospective study evaluated the comparative accuracy between the PAC and EDM for preload assessment and CO in mechanically ventilated surgical patients. METHODS The EDM was placed in 15 patients with PACs in place. A total of 187 simultaneously measured EDM and PAC comparative data sets were obtained. The Pearson correlation (r) was used to compare measurements, with significance defined as a value of p < 0.05. RESULTS: CO measured by EDM and PAC correlated closely (r = 0.97, p < 0.0001). Corrected flow time (FTc), a measure of left ventricular filling, correlated with PAC CO to the same degree as pulmonary capillary wedge pressure (PCWP) when positive end-expiratory pressure (PEEP) was < 10 cm H2O (FTc, r = 0.51; PCWP, r = 0.56). When PEEP was > or = 10 cm H2O, FTc correlated with PAC CO better than PCWP (FTc, r = 0.85; PCWP, r = 0.29). CONCLUSION: FTc correlates with EDM and PAC CO better than PCWP. On the basis of the current study, it is reasonable to conclude that the EDM is a valuable adjunct technology for CO and preload assessment in surgical patients on mechanical ventilation, regardless of the level of mechanical ventilatory support.