Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database.

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.

Evolution of Laparoscopic Surgery for Colorectal Cancer: The Impact of the Clinical Outcomes of Surgical Therapy Group Trial.

The Clinical Outcomes of Surgical Therapy Group (COST) Trial established laparoscopic procedures offer short-term benefits while preserving the same oncologic outcomes in colorectal cancer (CRC) patients compared with open procedures. The aim of this study was to evaluate the trend of laparoscopic resection for CRC before and after the publication of the COST Trial. Retrospective study of surgically treated CRC patients was conducted from January 2000 to December 2009. Surveillance, Epidemiology, and End Results Program and Medicare. Between 2000 and 2009, 147,388 patients underwent resection for CRC, 9,901 resections were performed laparoscopically. In 2000, 1.0 per cent of colorectal resections were performed laparoscopically. There was a dramatic increase in laparoscopic resections in 2009 to 30.4 per cent. During this time period, rates of laparoscopic resections increased for all tumor stages. Right colectomies and early stage tumors had the most significant rise from 3.1 per cent (2004) to 38.7 per cent (2009) and 4.41 per cent (2004) to 39.17 per cent (2009), respectively; whereas, rectal and later stage tumors resection rates were more modest from 2.1 per cent (2004) to 13.2 per cent (2009) and 1.41 per cent (2004) to 17.10 per cent (2009), respectively. This study demonstrates the COST Trial had a significant impact on utilization of laparoscopic colorectal resection for CRC. Although laparoscopic colorectal resections have been accepted for all types of CRCs, more difficult procedures are being adopted at slower rates.

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

INTRODUCTION: Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. METHODS: This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. RESULTS: Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. CONCLUSIONS: The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.