A Novel Approach to Analyze Disparities in Colorectal Cancer Screening and Mortality.

INTRODUCTION: Reducing disparities in colorectal cancer (CRC) screening rates and mortality remains a priority. Mitigation strategies to reduce these disparities have largely been unsuccessful. The primary aim is to determine variables in models of healthcare utilization and their association with CRC screening and mortality in North Carolina. METHODS: A cross-sectional analysis of publicly available data across North Carolina using variable reduction techniques with clustering to evaluate association of CRC screening rates and mortality was performed. RESULTS: Three million sixty-five thousand five hundred thirty-seven residents (32.1%) were aged 50 y or more. More than two-thirds (68.8%) were White, while 20.5% were Black. Approximately 61% aged 50 y or more underwent CRC screening (range: 44.0%-80.5%) and had a CRC mortality of 44.8 per 100,000 (range 22.8 to 76.6 per 100,000). Cluster analysis identified two factors, designated social economic education index (factor 1) and rural provider index (factor 2) for inclusion in the multivariate analysis. CRC screening rates were associated with factor 1, consisting of socioeconomic and education variables, and factor 2, comprised of the number of providers per 10,000 individuals aged 50 y or more and rurality. An increase in both factors 1 and 2 by one point would result in an increase in CRC screening rated by 6.8%. CRC mortality was associated with factor 2. An increase in one point in factor 1 results in a decrease in mortality risk by 10.9%. CONCLUSIONS: In North Carolina, using variable reduction with clustering, CRC screening rates were associated with the inter-relationship of the number of providers and rurality, while CRC mortality was associated with the inter-relationship of social, economic, and education variables.

Racial Disparity in the Surgical Management of Diverticular Disease.

INTRODUCTION: Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race. METHODS: Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race. RESULTS: Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001. CONCLUSION: There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.

A propensity score matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoidectomy in an enhanced recovery pathway.

Intracorporeal options for sigmoid resection have been recently developed but not extensively evaluated. This study was designed to assess outcomes comparing intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection in an established enhanced recovery pathway. This is a retrospective comparison of intracorporeal and extracorporeal techniques for robotic-assisted sigmoid resection for benign and malignant disease. Operative technique for the newer intracorporeal innovation is described in detail. Propensity score matching was performed using patient characteristics as predictors in the propensity score model. 169 cases met inclusion criteria. After propensity score matching, 114 cases were available for analysis (intracorporeal 57, extracorporeal 57). Almost 90% were for diverticulitis in each group. There were significantly fewer conversions in the intracorporeal group when compared to the extracorporeal group (5.26% vs. 19.3%, P = 0.029). Operative time was significantly longer in the intracorporeal group (193.33 vs. 159.89 min, P < 0.001). There was no significant difference between groups for time to flatus and bowel movements, hospital length of stay, postoperative 30-day complications, and readmission rates. There were significantly fewer extraction site hernias in the intracorporeal group (0 vs. 6 (10.53%), P = 0.027) likely because there were fewer midline extraction sites (8.77% vs. 38.6%, P < 0.001). When compared to extracorporeal techniques for robotic sigmoid resection in an enhanced recovery pathway, the intracorporeal approach is safe and associated with fewer conversions, fewer extraction site hernias, and longer operating times. As adoption of the intracorporeal approach continues to increase, further analysis of this technique in larger studies may be warranted.

A propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery Pathway.

INTRODUCTION: There may be short-term outcomes advantages for the intracorporeal approach to minimally invasive right colectomy. METHODS: This is a retrospective propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery colorectal surgery service. RESULTS: 55 intracorporeal and 55 extracorporeal cases were compared. Operative time was significantly longer (p < 0.001) and incision length shorter in the intracorporeal group (p = 0.007). Outcomes significantly favorable for the intracorporeal group included conversion-to-open (p = 0.013), time to first flatus (p < 0.001), time to first bowel movement (p = 0.006), and dehydration (p = 0.03). There were more extraction site hernias in the midline compared to off-midline locations, though this difference did not reach statistical significance (p = 0.06). CONCLUSION: There are outcomes advantages for the intracorporeal technique for robotic-assisted right colectomy when compared to the extracorporeal approach for patients in an Enhanced Recovery Pathway. Training efforts should continue to advocate the intracorporeal option.

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes.

BACKGROUND: Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach. METHODS: The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data. RESULTS: A total of 25,253 patients met inclusion criteria-21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality. CONCLUSIONS: Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.