Assessing preoperative frailty utilizing validated geriatric mortality calculators and their association with postoperative hip fracture mortality risk.

INTRODUCTION: End-of-life surgical care is a major concern with a significant number of operations performed within the last year of life; surgery for hip fractures is a prime example. Unfortunately, no simple objective tool exists to assess life expectancy in the postoperative period. The goal of our study was to analyze 2 simple geriatric life expectancy calculators to compare with the current Veterans Affairs Surgical Quality Improvement Program (VASQIP) postoperative 30-day mortality calculator. METHODS: This retrospective study assessed the utility of 3 validated calculators in 47 hip fracture repairs from July 2009 to May 2011. The tools included: 30-day VASQIP mortality calculator, 6-month Minimum Data Set Mortality Risk Index-Revised (MMRI-R), and Four-Year Mortality Index. The VASQIP calculator requires chart review, Current Procedural Terminology (CPT) codes, and laboratory analysis, whereas the mortality risk indices require simple patient questioning if prospective or simple chart review if retrospective. Scoring was performed and mortality risk was compared between survivors and nonsurvivors. RESULTS: A total of 47 hip fractures were repaired during the study period with 37 survivors and 10 nonsurvivors. In all, 7 died within 30 days, 2 died within 6 months, and 1 died greater than 6 months after surgery. The mean age (standard deviation [SD]) of all patients undergoing hip fracture repair was 73.6 (13.3) years. The VASQIP calculator mean (SD) 30-day mortality risk was 10.4% (5.4) for nonsurvivors compared to survivors 4.3% (5.5), P < .003; the MMRI-R mean (SD) mortality risk was 35.8% (15.4) for nonsurvivors compared to survivors 14.7% (9.5), P < .001; the Four-Year Mortality Index mean (SD) mortality risk was 60.9% (16.9) for nonsurvivors compared to survivors 48.9% (24.4), P < .09. CONCLUSION: Overall, the VASQIP 30-day and MMRI-R 6-month mortality calculators showed significant differences in mortality risk between survivors versus nonsurvivors in a population with hip fracture. In contrast, the Four-Year Mortality calculator may not sufficiently discriminate operative risk. The easily obtained MMRI-R has the potential to provide information on short-term postoperative mortality risk.

Perioperative outcomes after adrenalectomy for malignant neoplasm in laparoscopic era: a multicenter retrospective study.

BACKGROUND: This study aims to review perioperative outcomes of adrenalectomy for malignant neoplasm performed by open or laparoscopic technique and comparing them with benign diseases. METHODS: This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium is an alliance of over 100 academic medical centers and 250 affiliate hospitals. The University Health System Consortium database was accessed using International Classification of Diseases codes. RESULTS: A total of 6157 patients underwent adrenalectomy between January 2008 and June 2011. Of these, 5101 patients underwent open adrenalectomy (OA) and 1056 underwent adrenalectomy by laparoscopic technique (LA). Comparison between LA and OA showed lower morbidity (4.8% vs. 7.2%, P=0.0007), hospital length of stay (d) (3.23±5.66 vs. 4.35±6.59, P<0.0001), ICU admission rate (18.19% vs. 23.75%, P<0.0001), and cost ($) (9250±14306 vs. 11634±16547, P<0.0001) for LA, with no statistical difference in observed mortality or 30-day readmission rate. We then compared open and laparoscopic procedures performed for benign and malignant diagnoses. CONCLUSIONS: Overall, LA had better outcomes than OA. When comparisons were made between LA and OA for benign adrenal diseases, all outcomes were significantly better in the laparoscopic group. There were, however, no statistical differences when LA was compared with OA for malignant diagnoses.

Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection.

BACKGROUND: The aim of this study was to retrospectively compare the outcomes of laparoscopic abdominoperineal resection (APR) and open APR. METHODS: A multicenter, retrospective analysis was performed. The University HealthSystem Consortium database was accessed and searched for International Classification of Diseases, Ninth Revision, codes between October 2008 and January 2010. Discharge data were collected on patients undergoing laparoscopic APR and open APR. RESULTS: Six hundred sixty-seven patients underwent laparoscopic APR, and 2,443 underwent open APR. When lower risk patient groups with minor or moderate severity of illness were compared, laparoscopic APR showed lower morbidity, reduced length of stay, reduced cost, and reduced incidence of intensive care unit admission. Comparative analysis showed no significant difference in mortality rate or 30-day readmission. When higher risk patients were compared, there were significantly reduced costs and reduced incidence of intensive care unit cases in the laparoscopic group. CONCLUSIONS: Patients undergoing laparoscopic APR had overall superior perioperative outcomes compared with those undergoing open APR. Laparoscopic APR demonstrates excellent perioperative outcomes in appropriately selected patients.

Comparison of outcomes of laparoscopic and open appendectomy in management of uncomplicated and complicated appendicitis.

BACKGROUND: Several studies have demonstrated the superiority of the laparoscopic approach in uncomplicated and complicated appendicitis with conflicting results. As a result the role of laparoscopy in the management of appendicitis in general and complicated or perforated appendicitis, in particular, is still undefined. METHODS: A retrospective, observational study design was used to analyze multicenter outcomes using the University HealthSystem Consortium database. A 3-year discharge data of all open appendectomy (OA) and laparoscopic appendectomy (LA) procedures from 2006 to 2008 in adult patients older than 18 years for complicated or uncomplicated appendicitis was accessed using International Classification of Diseases, Ninth Revision codes. Data on several surgical outcome measures such as observed mortality, overall patient morbidity, intensive care unit admission rate, 30-day readmission rate, length of hospital stay, and hospital costs were collected from the University HealthSystem Consortium database. Stratification by University HealthSystem Consortium-specific severity of illness groups and disease diagnosis of complicated or perforated and uncomplicated appendicitis was performed. RESULTS: A total of 40,337 appendectomy procedures performed during 2006 to 2008 in adult patients were included in the study. Laparoscopic appendectomy for uncomplicated appendicitis resulted in significantly better surgical outcomes. However, surprisingly, these outcomes resulted in comparable but not significantly reduced hospital costs (7825 ± 6,009 for LA vs 7841 ± 13,147 for OA; P > 0.05). Laparoscopic appendectomy for complicated or perforated appendicitis showed lower mortality, reduced overall morbidity (17.43% for LA vs 26.68% for OA; P < 0.001), relatively less 30-day readmission rate, fewer intensive care unit admissions, significantly shorter length of hospital stay (4.34 ± 4.84 days for LA vs 7.31 ± 9.43 for OA; P < 0.001), and reduced hospital costs (12,125 ± 14,430 for LA vs 17,594 ± 28,065 for OA; P < 0.001) compared with patients undergoing OA. On stratification for severity of illness in both complicated and uncomplicated appendicitis, laparoscopic appendectomy resulted in a greater or comparable clinical benefit than open appendectomy. Comparable clinical benefit was observed in minor severity patients and moderate and major/extreme severity patients showed vastly improved surgical outcomes with the laparoscopic approach. CONCLUSIONS: Laparoscopic appendectomy is superior or comparable to open appendectomy in terms of several surgical outcome measures for both uncomplicated and complicated appendicitis, across most illness severity groups. Thus, laparoscopic appendectomy may be the preferred technique, irrespective of appendicitis diagnosis or disease severity.

Differences in outcomes of laparoscopic gastric bypass.

BACKGROUND: Although several risk factors affecting weight loss outcomes with bariatric procedures have been identified, the effect of age, gender, race, and illness severity on postoperative outcomes of laparoscopic gastric bypass has not been extensively examined. METHODS: The University HealthSystem Consortium database is an administrative and financial database that provides information on the inpatient stay. A retrospective analysis of patient outcomes was performed using 4-year discharge data from the University HealthSystem Consortium database. RESULTS: A total of 37,765 patients underwent laparoscopic gastric bypass. The women exhibited significantly reduced mortality, morbidity, intensive care unit (ICU) admissions (9.87% male versus 6.73% female; P <.001), duration of hospitalization (2.72 ± 4.03 d for men versus 2.59 ± 2.88 d for women; P <.001), and hospital costs ($17,346 ± $15,397 for men versus $14,383 ± $11,170 for women; P <.001). Blacks demonstrated significantly greater 30-day readmission rates, duration of hospitalization, and costs compared with whites. Hispanics had lower ICU admission and hospital costs compared with whites. With increasing age, an increased risk of overall morbidity, ICU admissions, duration of hospitalization, and costs was observed. Compared with the minor severity group, the major/extreme severity group had significantly greater observed mortality, overall morbidity, ICU admissions, duration of hospitalization, and hospital costs. CONCLUSION: The present study identified gender, race, age, and illness severity as risk factors affecting postoperative outcomes after laparoscopic gastric bypass. Male gender and increasing age were overall associated with an increased risk of complications. Significant racial disparities in the outcome measures were observed with blacks having an increased risk of adverse events. Illness severity was shown to adversely affect the surgical outcomes in laparoscopic gastric bypass.

Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia.

INTRODUCTION: There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity. METHODS: The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC's Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n=1,390) or ED (n=492) during a 3-year period between 2006 and 2008. RESULTS: Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p<0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p<0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p<0.001) and length of stay (2.23±1.78 LM vs. 4.88±4.42 days ED; p<0.001), but comparable cost ($9,539 LM vs. $8990 ED; p>0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p>0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p<0.001). However, the length of stay was significantly increased in the ED group (8.96±7.86 LM vs. 11.72±11.05 days ED; p=0.04). CONCLUSION: In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.

Safety, efficacy, and cost-effectiveness of common laparoscopic procedures.

BACKGROUND: Laparoscopic surgery has been shown to offer superior surgical outcomes for most abdominal surgical procedures. However, there is hardly any evidence on surgical outcomes with patient risk stratification. This study aimed to compare outcomes of common laparoscopic and open surgical procedures for varying illness severity. METHODS: A retrospective analysis of surgical outcomes for six commonly performed surgical procedures including cholecystectomy, appendectomy, reflux surgery, gastric bypass surgery, ventral hernia repair, and colectomy was performed using the University HealthSystem Consortium (UHC) Clinical Database/Resource Manager (CDB/RM). The 3-year discharge data for the six commonly performed laparoscopic surgical procedures were analyzed for outcome measures including observed mortality, overall patient morbidity, intensive care unit (ICU) admissions, 30-day readmissions, length of hospital stay, and hospital costs. RESULTS: In this study, 208,314 patients underwent one of six common surgical procedures by either the open or the laparoscopic approach. Overall, the laparoscopic approach showed significantly lower mortality, reduced morbidity, fewer ICU admissions and 30-day readmissions, shorter hospital stay, and significantly reduced hospital costs for all the procedures. At stratification by illness severity, the laparoscopic group showed better or comparable surgical outcomes across all the illness severity groups. However, the observed mortality was comparable for the minor and moderate severity patients between laparoscopic and open surgery for most procedures. The 30-day readmission rate for major/extreme severity patients was comparable between the two groups for most surgical procedures. CONCLUSIONS: This study demonstrated the superiority of laparoscopy over conventional open surgery across all illness severity risk groups for common surgical procedures. The results in general show that laparoscopic surgery is safe, efficacious, and cost-effective compared with open surgery and suggest that laparoscopic surgery should be the procedure of choice for all common surgical procedures, regardless of illness severity.

Primary and revisional laparoscopic adjustable gastric band placement in patients with hiatal hernia.

BACKGROUND: Limited evidence exists regarding the outcomes of patients undergoing laparoscopic adjustable band placement (LAGB) with hiatal hernia (HH) and concomitant hiatal hernia repair (HHR). The present study evaluated the safety, efficacy, and cost-effectiveness of primary LAGB (pLAGB) and revisional LAGB (rLAGB) in patients with HH. METHODS: The University HealthSystem Consortium is an alliance of >100 academic medical centers and nearly 200 affiliate hospitals. The University Health System Consortium database was queried for patients undergoing LAGB with and without HH from 2006 through 2009. RESULTS: The patients undergoing rLAGB had a significantly greater prevalence of HH than patients undergoing pLAGB (18.9% for pLAGB with HH versus 26.3% for rLAGB with HH; P <.001). The mortality (.04% for pLAGB without HH versus 0% for pLAGB with HHR; P >.05), morbidity (3.39% pLAGB without HH versus 2.63% for pLAGB HHR; P >.05), and length of stay (1.33 ± 2.25 days for pLAGB without HH versus 1.17 ± 0.56 days for pLAGB with HHR; P >.05) were comparable in the patients undergoing pLAGB with or without HHR. A trend was seen toward increased morbidity in patients undergoing rLAGB HHR than in those undergoing pLAGB HHR (2.63% for pLAGB HHR versus 13.33% for rLAGB HHR; P = .08). The length of stay (1.17 ± 0.56 days for pLAGB HHR versus 1.73 ± 1.49 days for rLAGB HHR; P <.01) and hospital costs ($12,178 ± 4451 for pLAGB HHR versus $14,616 ± 3538 for rLAGB HHR; P = .04) were increased for the rLAGB HHR group compared with the pLAGB HHR group. CONCLUSION: The results of the present study have demonstrated the safety of HHR concomitant with pLAGB. In addition, rLAGB was associated with increased morbidity and cost. These data suggest the safety, efficacy, and cost-effectiveness of crural repair of HH simultaneously with pLAGB.

Reoperative laparoscopic paraesophageal herniorrhaphy can produce excellent outcomes.

BACKGROUND: Patients undergoing laparoscopic paraesophageal herniorrhaphy present with various esophageal and extraesophageal symptoms. Given a recurrence rate of up to 44%, reoperative intervention is necessary on a number of patients. The goal of this study is to determine whether patients proceeding with reoperative laparoscopic paraesophageal herniorrhaphy experienced symptom resolution equal to or better than patients undergoing first-time repair. METHODS: A frequency-based symptom assessment consisting of 24 esophageal and extraesophageal reflux symptoms was developed and administered pre- and postoperatively to patients undergoing initial or reoperative paraesophageal herniorrhaphy during a 7-year period. A composite score for esophageal and extraesophageal symptoms was calculated. Retrospective analysis of patient records including diagnostic studies, and operative and postoperative progress notes was performed. Data were analyzed using appropriate statistical tests. RESULTS: In 195 patients, 89.9% of patients had resolved or improved individual symptom scores at 6 months postoperatively after primary or reoperative paraesophageal herniorrhaphy. Paraesophageal herniorrhaphy resulted in improvements of both esophageal (16.1±8.5 preoperatively versus 3.5±5.0 at 6 months postoperatively; p<0.001) and extraesophageal (8.6±7.5 preoperatively versus 2.2±5.1 at 6 months postoperatively; p<0.001) composite scores and all individual symptom scores (p<0.05). Preoperatively, patients undergoing reoperative surgery had significantly higher solid dysphagia and abdominal discomfort, but lower odynophagia scores. Furthermore, reoperative patients had significantly lower preoperative composite extraesophageal scores (6.1±7.2 reoperative versus 9.1±7.5 primary; p<0.05) and individual symptom scores in laryngitis, hoarseness, and coughing. Only heartburn in reoperative patients was significantly higher at 12 months postoperatively. Otherwise, there was no significant difference in individual or composite symptom scores between groups postoperatively. All scores had significant improvement postoperatively when compared with preoperative scores. CONCLUSIONS: Our data demonstrate that reoperative laparoscopic paraesophageal herniorrhaphy can produce excellent results, comparable to first-time repair.

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives.

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.

Short- and long-term outcome for living pancreas donors.

The advantages of living donor pancreas transplants for the recipient include good HLA matching, lower immunologic risk, less immunosuppression, lower risk of infection and of posttransplant malignancies, and shorter pancreas graft preservation time. In 2008, a total of 155 segmental pancreas transplants using living donors were reported to the International Pancreas Transplant Registry from six countries. Pancreas living donors need to undergo a thorough pretransplant endocrinologic workup in order to minimize the risk of metabolic complications. The pretransplant workup has evolved over time, after initial reports showed that up to 25% of living donors had elevated hemoglobin A(1c) levels after donation. Avoiding obesity after donation diminishes the risk of long-term metabolic complications. The risk of surgical complications for the donor (such as pancreatitis, pancreatic leak or fistula, pancreatic abscess, and pancreatic pseudocyst) is less than 5%. If both the donor and recipient operations are technically successful, the long-term graft survival rate is significantly higher for living (versus deceased) donor pancreas transplant recipients. Future long-term studies of metabolic function in living donors are warranted to determine whether living donor pancreas transplants can safely be applied more widely and whether living donors can be used for islet transplants.