Surgical errors and the relationships of disease, risks, and adverse events.

BACKGROUND: Relationships between surgical errors and adverse events have not been fully explored and were examined in this study. MATERIALS AND METHODS: This retrospective cohort study reviewed records of deceased surgical patients over 12 months. Bivariate associations between predictors and errors were examined. RESULTS: 84 deaths occurred following 5,209 operations. Errors in care (63%) compared to those without had significantly more adverse events, (98% vs 80% respectively, p = 0.004). Significant association occurred between error and emergency status, p = 0.016); length of stay >10 days, p = 0.011; adverse events, p = 0.005). Regression results indicated number of adverse events (OR = 1.27, 95% CI (1.08-1.49), p = 0.003) and length of stay (OR = 1.05, 95% CI (1.01-1.09), p = 0.008) were associated with surgical errors. CONCLUSIONS: Examining postoperative adverse events in error cases identified opportunities for improvement. Reducing medical errors requires measuring medical errors.

Robotic compared with laparoscopic cholecystectomy: A propensity matched analysis.

BACKGROUND: As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy. MATERIALS AND METHODS: All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ2 test and continuous variables using the Mann-Whitney U test. RESULTS: A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy. CONCLUSION: Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy.

Inguinal hernia repair: is there a benefit to using the robot?

BACKGROUND: The number of robotic surgical procedures performed yearly is constantly rising, due to improved dexterity and visualization capabilities compared with conventional methods. We hypothesized that outcomes after robotic-assisted inguinal hernia repair would not be significantly different from outcomes after laparoscopic or open repair. METHODS: All patients undergoing inguinal hernia repair between 2012 and 2016 were identified using institutional American College of Surgeons National Surgical Quality Improvement Program data. Demographics; preoperative, intraoperative, and postoperative characteristics; and outcomes were evaluated based on method of repair (Robot, Lap, or Open). Categorical variables were analyzed by Chi-square test and continuous variables using Mann-Whitney U. RESULTS: A total of 510 patients were identified who underwent unilateral inguinal hernia repair (Robot: 13.8% [n = 69], Lap: 48.1% [n = 241], Open: 38.1% [n = 191]). There were no demographic differences between groups other than age (Robot: 52 [39-62], Lap: 57 [45-67], and Open: 56 [48-67] years, p = 0.03). Operative duration was also different (Robot: 105 [76-146] vs. Lap: 81 [61-103] vs. Open: 71 [56-88] min, p < 0.001). There were no operative mortalities and all patients except one were discharged home the same day. Postoperative occurrences (adverse events, readmissions, and death) were similar between groups (Robot: 2.9% [2], Lap: 3.3% [8], Open: 5.2% [10], p = 0.53). Although rare, there was a significant difference in rate of postoperative skin and soft tissue infection (Robot: 2.9% [2] vs. Lap: 0% [0] vs. Open: 0.5% [1], p = 0.02). Cost was significantly different between groups (Robot: $7162 [$5942-8375] vs. Lap: $4527 [$2310-6003] vs. Open: $4264 [$3277-5143], p < 0.001). CONCLUSIONS: Outcomes after robotic-assisted inguinal hernia repair were similar to outcomes after laparoscopic or open repair. Longer operative duration during robotic repair may contribute to higher rates of skin and soft tissue infection. Higher cost should be considered, along with surgeon comfort level and patient preference when deciding whether inguinal hernia repair is approached robotically.

Sex- and diagnosis-dependent differences in mortality and admission cytokine levels among patients admitted for intensive care.

OBJECTIVES: To investigate the role of sex on cytokine expression and mortality in critically ill patients. DESIGN: A cohort of patients admitted to were enrolled and followed over a 5-year period. SETTING: Two university-affiliated hospital surgical and trauma ICUs. PATIENTS: Patients 18 years old and older admitted for at least 48 hours to the surgical or trauma ICU. INTERVENTIONS: Observation only. MEASUREMENTS AND MAIN RESULTS: Major outcomes included admission cytokine levels, prevalence of ICU-acquired infection, and mortality during hospitalization conditioned on trauma status and sex. The final cohort included 2,291 patients (1,407 trauma and 884 nontrauma). The prevalence of ICU-acquired infection was similar for men (46.5%) and women (44.5%). All-cause in-hospital mortality was 12.7% for trauma male patient and 9.1% for trauma female patient (p = 0.065) and 22.9% for nontrauma male patients and 20.6% for nontrauma female patients (p = 0.40). Among trauma patients, logistic regression analysis identified female sex as protective for all-cause mortality (odds ratio, 0.57). Among trauma patients, men had significantly higher admission serum levels of interleukin-2, interleukin-12, interferon-γ, and tumor necrosis factor-α, and among nontrauma patients, men had higher admission levels of interleukin-8 and tumor necrosis factor-α. CONCLUSIONS: The relationship between sex and outcomes in critically ill patients is complex and depends on underlying illness. Women appear to be better adapted to survive traumatic events, while sex may be less important in other forms of critical illness. The mechanisms accounting for this gender dimorphism may, in part, involve differential cytokine responses to injury, with men expressing a more robust proinflammatory profile.

Differences in morbidity and mortality with percutaneous versus open surgical drainage of postoperative intra-abdominal infections: a review of 686 cases.

Intra-abdominal infections following surgical procedures result from organ-space surgical site infections, visceral perforations, or anastomotic leaks. We hypothesized that open surgical drainage is associated with increased patient morbidity and mortality compared with percutaneous drainage. A single-institution, prospectively collected database over a 13-year period revealed 2776 intra-abdominal infections, 686 of which required an intervention after the index operation. Percutaneous procedures (simple aspiration or catheter placement) were compared with all other open procedures by univariate and multivariate analyses. Analysis revealed 327 infections in 240 patients undergoing open surgical drainage and 359 infections in 260 patients receiving percutaneous drainage. Those undergoing open drainage had significantly higher Acute Physiology Score (APS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and were more likely to be immunosuppressed, require intensive care unit treatment, and have longer hospital stays. Mortality was higher in the open group: 14.6 versus 4.2 per cent (P = 0.0001). Variables independently associated with death by multivariate analysis were APACHE II, dialysis, intensive care unit (ICU) care, age, immunosuppression, and drainage method. Open intervention for postsurgical intra-abdominal infections is associated with increased mortality compared with percutaneous drainage even after controlling for severity of illness by multivariate analysis. Although some patients are not candidates for percutaneous drainage, it should be considered the preferential treatment in eligible patients.

Does preoperative ejection fraction predict operative mortality with left ventricular restoration?

BACKGROUND: Ischemic cardiomyopathy and aneurysmal disease have been treated surgically with coronary artery bypass grafting in the past. The Dor technique for left ventricular restoration has demonstrated improved outcomes in patients with ischemic, akinetic ventricles. Our hypothesis was that even marked reduction in preoperative cardiac function (ejection fraction < .25) would not correlate with worse outcomes since the ventricle would be reshaped to improve function. METHODS: A retrospective analysis was performed on all patients who had undergone ventricular restoration with the Dor procedure from January 1996 through September 2005. Patients with a preoperative ejection fraction (EF) < .25 and those with a EF > or = .25 were compared. All Society of Thoracic Surgeons database characteristics, mortality, length of stay (LOS), and need for intraaortic balloon pump (IABP) were analyzed. RESULTS: The study included 89 patients (69 men, 20 women), 28 of whom had preoperative EFs < .25 (mean, .183 +/- .035; range, .08 to .25) and 61 had an EF > or = .25 (mean, .334 +/- .074; mean, .25 to .45). Overall operative mortality was 3.4% (3/89), with no statistically significant difference between the two groups (3.6% versus 3.3%). LOS was 7.4 +/- 3.6 days versus 8.9 +/- 15.6 days (p = NS), and need for IABP was 39.2% versus 8.1% (p < 0.05). Overall 5-year survival was 82%. Five-year survival in the EF < .25 cohort was 69.6% versus 88.3% in the EF > or = .25 cohort (p = 0.066). CONCLUSIONS: Ventricular restoration with the Dor technique is a safe procedure. Marked reduction in ejection fraction is not a contraindication to left ventricular restoration; however, increased usage of IABP should be anticipated.