RESUMEN
BACKGROUND: Since the introduction of laparoscopic colectomy, experience and technology continue to improve. Although accepted for many colorectal conditions, its use and outcomes in complex procedures are less understood. OBJECTIVE: The purpose of this work was to compare the perioperative outcomes of laparoscopic transverse colectomy and total abdominal colectomy (study group) with an open approach (comparative group) and the more established laparoscopic right, left, and sigmoid colectomies (control group). DESIGN: This was a retrospective review of the Nationwide Inpatient Sample (2008-2011) of all patients undergoing elective right, left, sigmoid, total, or transverse colectomy as identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedures. SETTINGS: The study included a national sample from a population database. PATIENTS: There were 45,771 admissions: 2946 in the study group, 36,949 in the control group, and 5876 in the open comparative group. MAIN OUTCOME MEASURES: Mortality was the primary outcome. Secondary outcomes included in-hospital complications, length of stay, and hospital charges. RESULTS: The patients were predominantly white (73%), had private insurance (64%), and underwent surgery at urban centers (92%). Mortality was similar between the study and control groups (0.42% vs 0.51%; p = 0.52), with a higher complication rate in the study group (19% vs 14%; p < 0.01). The study group was also associated with a lower mortality rate compared with the open group (0.51% vs 2.20%; p < 0.01), which remained consistent after adjusting for covariates (OR, 0.38 [95% CI, 0.20-0.71]; p < 0.01). The study group had fewer complications overall compared with the open group (19% vs 27%; p < 0.01) and a shorter median length of stay (4.6 vs 6.3 days; p < 0.01). LIMITATIONS: This was a retrospective study using an administrative database. CONCLUSIONS: A laparoscopic approach for total abdominal and transverse colectomies has similar mortality rates and slightly higher complications than the more established laparoscopic colectomy procedures and improved perioperative outcomes when compared with an open technique (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A178).
Asunto(s)
Colectomía/métodos , Laparoscopía/métodos , Tiempo de Internación/estadística & datos numéricos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Anciano , Colectomía/efectos adversos , Colectomía/mortalidad , Femenino , Humanos , Laparoscopía/efectos adversos , Laparoscopía/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Puntaje de Propensión , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Although minimally invasive colorectal surgery increases widely, outcomes following its use in complex operations such as the abdominoperineal resection (APR) remain indeterminate. METHODS: A review of the Nationwide Inpatient Sample (2008 to 2011) of all patients undergoing elective laparoscopic or open APR was conducted. Risk-adjusted 30-day outcomes were assessed using regression modeling accounting for patient characteristics, comorbidities, and surgical procedure. RESULTS: We identified 3,191 admissions meeting inclusion criteria (1,019 laparoscopic; 2,172 open). The conversion rate was 5%. Mortality was low and similar between groups (.88% vs .83%, P = .91). In-hospital complication rates were lower in the laparoscopic group (19% vs 29%, odds ratio .59, 95% confidence interval .49 to .71, P < .01), but conversion was associated with a higher rate (29% vs 18%, P < .01). Finally, a laparoscopic APR was associated with a shorter length of stay (5.3 vs 7.0 days, P < .01). CONCLUSION: Laparoscopic APR is associated with improved outcomes and may be the preferred approach by surgeons with appropriate skills and experience.
Asunto(s)
Abdomen/cirugía , Cirugía Colorrectal/métodos , Procedimientos Quirúrgicos Electivos/métodos , Laparoscopía/estadística & datos numéricos , Laparotomía/estadística & datos numéricos , Perineo/cirugía , Vigilancia de la Población , Adolescente , Adulto , Anciano , Femenino , Hawaii/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Morbilidad/tendencias , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Adulto JovenRESUMEN
BACKGROUND: Hemorrhoidectomy is considered by many to be a contaminated operation that requires antibiotic prophylaxis to lower the incidence of surgical site infection. In reality, little evidence exists to either support or refute the use of antibiotic prophylaxis in this setting. OBJECTIVE: This study aimed to determine if antibiotic prophylaxis is associated with reduced incidence of postoperative surgical site infection following hemorrhoidectomy. DESIGN: This is a retrospective database review. SETTING: This study was conducted at multiple institutions. PATIENTS: All patients undergoing hemorrhoidectomy with minimum 3-month follow-up were included. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of postoperative surgical site infection. RESULTS: Eight hundred fifty-two patients met the inclusion criteria (50.1% female; mean age, 50.0 ± 13.7 years). The prevalence of preoperative risk factors for surgical site infection included 7.7% with a smoking history, 2.5% with diabetes mellitus, 0.8% receiving steroids, and 0.2% with Crohn's disease. Surgery was performed predominately for 3-column prolapsed internal and mixed internal/external hemorrhoidal disease. All surgeries performed were closed hemorrhoidectomies. Antibiotic prophylaxis was used in a fewer number of cases (41.3% vs 58.7%). Overall, there were only 12 documented postoperative infections identified, producing an overall incidence of 1.4%. Of those patients who developed postoperative surgical site infections, 9 (75%) did not receive antibiotic prophylaxis (p = 0.25). On multivariate regression analysis, no perioperative risk factor was associated with an increased risk of developing a posthemorrhoidectomy surgical site infection. Conversely, there were no adverse antibiotic-related complications such as Clostridium difficile colitis or antibiotic-associated diarrhea in those receiving antibiotic prophylaxis. LIMITATIONS: This study was limited by the retrospective nature of the analysis. CONCLUSIONS: Postoperative surgical site infection is an exceedingly rare event following hemorrhoidectomy. Antibiotic prophylaxis does not reduce the incidence of postoperative surgical site infection, and its routine use appears unnecessary.
Asunto(s)
Profilaxis Antibiótica , Hemorreoidectomía , Infección de la Herida Quirúrgica/prevención & control , Comorbilidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiologíaRESUMEN
BACKGROUND: During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery. METHODS: A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups. RESULTS: A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery. CONCLUSIONS: RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.
Asunto(s)
Colectomía/economía , Colectomía/estadística & datos numéricos , Laparoscopía/economía , Laparoscopía/estadística & datos numéricos , Robótica/economía , Robótica/estadística & datos numéricos , Colectomía/métodos , Costos y Análisis de Costo , Femenino , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Tempo Operativo , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Robótica/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available. OBJECTIVE: Assessment of feasibility of endoluminal full-thickness closure. DESIGN: Prospective, open-label, interventional study. SETTING: Tertiary referral center. PATIENTS: Patients referred to surgery for endoscopically unresectable polyps. INTERVENTIONS: Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system. MAIN OUTCOME MEASUREMENTS: Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up. RESULTS: Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place. LIMITATIONS: Small number of patients, single-center feasibility study without control arm. CONCLUSIONS: Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00553436.).
Asunto(s)
Colon/cirugía , Pólipos del Colon/cirugía , Colonoscopía/métodos , Mucosa Intestinal/cirugía , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. METHODS: By using a database with prospectively collected data, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic surgeries were performed in 42 patients and were compared with 25 patients who were suitable for laparoscopy but received open colectomy. RESULTS: The groups had similar demographics with no differences in age, sex, or surgical indications. Blood loss was lower (118 vs 205 mL; P < 0.01) and the postoperative stay was shorter (8 vs 11 d; P = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the 2 groups (1 vs 3; P = 0.29). CONCLUSIONS: With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open surgery.
Asunto(s)
Enfermedades del Colon/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Colectomía , Bases de Datos como Asunto , Urgencias Médicas , Estudios de Factibilidad , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
BACKGROUND: Colonic ischemia after open repair of ruptured abdominal aortic aneurysm (rAAA) has been reported to be as high as 42% and is associated with high mortality rates when transmural necrosis is involved. With the evolution of endovascular aortic repair (EVAR) devices, some centers now primarily use this technique for rAAA. The objective of this study was to determine the incidence of colonic ischemia after EVAR of rAAA. STUDY DESIGN: All patients who underwent EVAR of rAAA from January 2002 to January 2006 were included in this review. All flexible sigmoidoscopies were performed within 48 hours, ischemia was graded consistently, and treatment was initiated per protocol based on grade of ischemia. Patients with grades I and II ischemia were followed up with medical management and in some cases, repeat colonoscopy. All patients with grade III ischemia underwent bowel resection. RESULTS: Forty-four patients underwent EVAR of rAAA during the study period. Operative mortality was 11%. Sigmoidoscopy was performed in 36 of 39 patients who survived longer than 24 hours. Bowel ischemia was documented in 8 of the 36 patients (23%). Of these, five had grade I or grade II ischemia at both initial and repeat endoscopy, so these patients did not progress to resection. Three patients underwent exploratory laparotomy with bowel resection because of grade III ischemia; one of these procedures was performed for worsening ischemia discovered at repeat colonoscopy. CONCLUSIONS: This study demonstrated that the overall incidence of colonic ischemia (23%) after EVAR of rAAA is less than that reported for the open repair. We would continue to recommend mandatory flexible sigmoidoscopy for these patients.