Difference In Perioperative Complication Rates Research Articles

Single-incision Laparoscopic Colonic Surgery: A Systemic Review, Meta-analysis, and Future Prospect.

Although single-incision laparoscopic surgery (SILS) has gained some attention as a feasible alternative to conventional multiport laparoscopic surgery (MPLS) in colonic surgery, it became less prevalent than expected. Hence, we conducted this systematic review to evaluate the feasibility, safety, and oncological outcomes of single-incision laparoscopic colectomy (SILC) with meta-analysis and discussion of the future prospect of SILS. The search was conducted from September to October 2023 using PubMed and the Cochrane Central Register of Controlled Trials. Articles on colorectal cancer comparing SILC with multiport laparoscopic colectomy (MPLC) from all randomized controlled trials and comparative studies with 50 patients or more per arm were examined. The primary outcomes were the intra- and postoperative complication rates, and the secondary outcomes were the perioperative and oncological outcomes. The trends of the SILS number in Japan and the trends of the number of articles on SILS in PubMed were also reviewed. There were no significant differences in perioperative complication rates, operative factors, and oncological outcomes between SILC and MPLC, although heterogeneity was observed mainly in operative factors and the total length of the skin incision was significantly shorter in SILC. Therefore, SILC is technically and oncologically feasible and safe when performed by experienced laparoscopic surgeons. The case number of SILS was gradually increasing but the rate of SILS was decreasing in Japan. The number of articles on SILS was also decreasing. SILS has gained foothold to some extent but has plateaued. The emerging new robotic platform may reappraise the concept of SILS.

Comparison of the mid-term clinical efficacy of different fixtaion methods combined with oblique lumbar interbody fusion in treating lumbar degenerative diseases.

To compare the mid-term follow-up clinical efficacy among three treatment approaches for lumbar degenerative diseases (LDD): standalone oblique lumbar interbody fusion (SF), oblique lumbar interbody fusion combined with lateral screw fixation (LF), and oblique lumbar interbody fusion combined with posterior screw fixation (PF). This retrospective study included a total of 71 cases of single level LDD that underwent OLIF in Hospital of Chengdu University of Traditional Chinese Medicine were retrospectively collected between March 2016 and September 2017. Patients were divided into three groups: 24 cases in the SF group, 24 cases in the LF group and 23 cases in the PF group. Various parameters, such as operation time, hospitalization time, and complications, were recorded. The fusion condition was assessed at last follow up. Clinical outcomes were evaluated using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) from pre-operation to 5years post-surgery. Significantly lower mean operation time and hospitalization time were observed in the SF and LF groups compared to the PF group (p < .05). However, no significant difference in fusion rate was found among the three groups. Regarding clinical outcomes, there was no statistically significant difference in VAS scores between the three groups during all follow-up periods. At the 6th month and 1st year after surgery, the SF and LF groups had significantly lower Oswestry Disability Index (ODI) scores compared to the PF group (p < .05). There was no significant difference in perioperative complication rates among the three groups (p > .05). In the LF group, one case of instrument displacement and urethra injury were reported, while in the SF, LF, and PF groups, 10, 9, and 3 cases of cage subsidence were reported, respectively. The study findings suggest that oblique lumbar interbody fusion (OLIF) is a safe and effective treatment for mid-term management of lumbar degenerative diseases (LDD). Compared to the posterior screw fixation (PF) group, both the standalone OLIF (SF) and OLIF combined with lateral screw fixation (LF) groups showed advantages in terms of reduced operation time, shorter hospitalization, and faster symptom alleviation in the short-term. However, OLIF combined with PF demonstrated comparable symptom relief in the mid-term and had the additional benefit of lower cage subsidence rates while improving fusion rates as well.

Comparison of the Clinical Outcomes and Complications of Simultaneous vs Staged Bilateral Total Ankle Arthroplasty: A Single-Center Comparative Cohort Study

Category: Ankle Arthritis; Ankle; Hindfoot Introduction/Purpose: The utilization of total ankle arthroplasty (TAA) has increased over the past decade to include bilateral TAAs. The risk-benefit profiles of simultaneous versus staged joint arthroplasty continues to be debated in the literature. There are limited case series reporting outcomes after bilateral TAA with no previous comparison of simultaneous versus staged TAA. It is important to study patients with bilateral pathology as they represent a unique population often with a differing arthritis etiology and an overall more debilitating condition. Thus, we aim to compare bilateral simultaneous versus staged TAAs including perioperative complications and patient reported outcome measures (PROMs). Methods: We performed a comparative cohort study of patients who underwent primary TAA from 2007 to 2019 at a single academic center. Inclusion criteria were primary bilateral TAA performed in simultaneous or staged fashion in patients over 18 years of age. Exclusion criteria were patients with less than two-years follow-up and those with previous tibiotalar arthrodesis or infection. Patient demographics, comorbidities, perioperative complications, and PROMs were collected. PROMs included preoperative and postoperative visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Short Musculoskeletal Function Assessment (SMFA) bother and function sub-scores. Bivariate tests of significance were used to compare variables between the two cohorts. Results: Fifty patients were included with an average clinical follow-up was 52.2 (+-27.3; range 24-109) months. The mean time between staged TAA surgeries was 17.5 months (+-20.1, range 3-74). The mean age was 64.3 (+-10.6, range 21-76) years with 32 (64.0%) men. Many patients had primary osteoarthritis (n=28, 56.0%). Both cohorts experienced improvement in all PROMs at one year, which were maintained at final follow-up with no significant between-group differences (p &gt;0.05). There were no differences in perioperative complication rates with similar overall complications (22.0% vs. 24.0%; p=0.7788) and reoperations (6.0% vs 5.0%; p=0.7354) between the simultaneous and staged cohorts, respectively. The two-year and five-year reoperation-free survival were 96.0% and 90.0% for the staged cohort and 94.0% and 88.0% for the simultaneous cohort, respectively (p=0.4612) Both cohorts had 100% failure-free survival up to eight-years postoperative. One patient in the simultaneous cohort required metal component revision at eight years postoperative. Conclusion: The results of bilateral simultaneous TAA, including patient reported outcomes, perioperative complications, and component survival are comparable to patients undergoing staged TAA. When performed under surgeon expertise in appropriately selected patients, we advocate that simultaneous bilateral TAA is a safe and effective method for the treatment of bilateral end-stage ankle osteoarthritis. Potential benefits of simultaneous TAA warranting further investigation include decreased anesthesia events, surgery time, tourniquet time, length of hospitalization, recovery and rehabilitation time, and overall cost. Future investigations will include dedicated analyses of radiographic outcomes and cost comparisons between these two cohorts.

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients.

The purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group. This was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge. From 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR]= 1.51, P= .001), acute kidney injury (OR= 2.02, P < .001), and discharge to facility (OR= 1.67, P= .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR= 1.82, P < .001 and OR= 1.60, P= .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA. In this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA. 3 (Retrospective cohort study).

Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review.

Benign prostatic hyperplasia (BPH) is a common health condition in aging men resulting in lower urinary tract symptoms (LUTS) and low quality of life (QoL). We aimed to review studies on laser enucleation of the prostate (LEP) due to LUTS in elderly patients (>65 years) comparing different age groups, particularly considering functional outcomes, safety, and perioperative complications. A comprehensive search was conducted using the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases over the last 10 years until 7 October 2021 with the following search terms solely or in combination: “laser enucleation”, “prostate”, “laser prostatectomy”, “aging”, “elderly patients”, “older patients” and “age”. We identified 12 articles for inclusion in our analysis. Five studies focussed mainly on holmium laser enucleation of the prostate (HoLEP), one compared HoLEP to other laser prostatectomy procedures, two studies examined thulium laser enucleation of the prostate (ThuLEP), and two studies focused on GreenLight laser, one study focussed on potassium-titanyl-phosphate (KTP) laser, and another study compared laser prostatectomy to transurethral resection of the prostate (TURP). These studies showed that LEP improved IPSS, Qmax and QoL compared to baseline regardless of age; no significant difference was reported among age groups. Although ASA scores and anticoagulation/antiplatelet therapy rates are higher in elderly patients, studies revealed no significant difference in perioperative complication rates between age groups. Laser enucleation of the prostate is an effective and safe procedure in elderly patients, resulting in good functional outcomes, low morbidity, and few perioperative complications.

Cleft Palate Repair in Robin Sequence following Mandibular Distraction Osteogenesis Compared to Tongue-Lip Adhesion.

To evaluate the timing and safety of cleft palate (CP) repair in patients with Robin sequence (RS) treated with mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA) for airway obstruction. Retrospective cohort study. Tertiary Pediatric Hospital during 2004-2020. 148 patients with RS underwent MDO, 66 met inclusion by having MDO and followed by palatoplasty. 26 patients with RS underwent TLA, 14 met inclusion by having TLA and followed by palatoplasty. Patient characteristics, hospital/operative details, postoperative complications, and polysomnographic (PSG) data were compared. Groups were well-matched except more patients with syndromes underwent MDO (N = 27, 41%, P ≤ .002). In the MDO and TLA cohorts, mean CP repair age was 12.8 ± 1.9 months and 14.6 ± 1.6 months, respectively (P ≤ .002). Despite the earlier CP repair in the MDO group, there were no differences in peri-operative complication rates after palatoplasty in either group. All sleep respiratory parameters improved after MDO/TLA prior to palatoplasty P ≤ .050. All PSG parameters remained significantly improved after palatoplasty compared to preoperative values, P ≤ .043. Obstructive apnea hypopnea index and Oxygen saturation nadir further improved after palatoplasty within the MDO group, P ≤ .050, while no changes in the TLA group, P ≥ .500. MDO was associated with earlier age at palatoplasty than TLA with a similar perioperative risk profile. In those patients with pre- and post-palatoplasty PSG data, palatoplasty was not associated with a deterioration in PSG parameters, and in fact in the MDO group, PSG data improved.

Laparoscopic uterosacral ligament suspension versus sacrospinous ligament fixation for apical prolapse: perioperative outcomes

BackgroundPelvic organ prolapse can be repaired vaginally or laparoscopically. Studies comparing vaginal repair with sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (V-USLS) have found no difference in functional or adverse outcomes. Laparoscopic USLS (L-USLS) is becoming a popular treatment for pelvic organ prolapse because it has a low rate of ureteral compromise. To date, no studies have compared perioperative outcomes between L-USLS and SSLF. The objective of this study is to compare the rates of perioperative complications between these two methods.MethodsThis was a retrospective chart review of 243 consecutive patients who underwent L-USLS or SSLF at one institution between March 2017 and August 2019 for apical pelvic organ prolapse. Descriptive data was analyzed as appropriate with Student’s t tests and chi-square. Univariable logistic regression analysis was performed to assess predictors of perioperative complications.ResultsPreoperative Pelvic Organ Prolapse Quantification Stage (POP-Q) was similar between the two cohorts (p = 0.23). After adjusting for confounding factors, L-USLS was associated with a longer operative time (118 vs 142 min, p < 0.01) and shorter length of hospitalization (0.68 vs 1.06 days, p < 0.01). The estimated blood loss between the procedures was not statistically significant after adjusting for confounding factors. There was no difference in perioperative complication rates between L-USLS and SSLF (5% vs 7%, p = 0.55). No clinical risk factors were significantly associated with perioperative complications.ConclusionWe did not find a difference in complications between L-USLS and SSLF.

Endo-Satinsky Clamp Hybrid In Situ Perfusion in Retroperitoneoscopic Donor Nephrectomy For Right-sided Kidney

ObjectiveTo introduce our hybrid technique using an endo-Satinsky clamp and in situ cold perfusion for right-sided retroperitoneoscopic donor nephrectomy (RDN) and to investigate efficacy and safety compared with those standard right-sided RDN. MethodsThis retrospective study included 16 transplant donors who underwent right-sided RDN from January 2016 to January 2018. Donors received either hybrid RDN (n = 6) or standard RDN (n = 10). Perioperative outcomes, including operative time, estimated blood loss, warm ischemic time, hospital stay, length of renal vein obtained as well as postoperative renal function of their recipients were collected and compared between the hybrid RDN and standard RDN groups. ResultsProcedures were performed successfully in all 16 donors. The hybrid RDN group required longer operation times (135 vs 115 minutes), demonstrated increased blood loss (175 vs 140 mL), but shorter warm ischemic times (1.5 vs 5.5 minutes) and resulted in longer length of the procured renal vein (2.8 vs 1.7 cm) as compared with the standard RDN group. No difference in perioperative complication rates was witnessed between the 2 groups. Also, there were no significant differences in serum creatinine levels and glomerular filtration rates of recipients between the 2 groups at both postoperative day 3 and 1 month. ConclusionThe hybrid RDN potentially extends the length of the right donor renal vein. The perioperative outcomes of hybrid RDN were comparable with those of the standard RDN. This hybrid technique can be a technically safe and feasible option for right kidney donation.

Comparative outcomes between robotic and abdominal radical hysterectomy for IB1 cervical cancer: Results from a single high volume institution

ObjectiveTo compare the perioperative morbidity and survival between abdominal radical hysterectomy (ARH) and robotic radical hysterectomy (RRH). MethodsA retrospective cohort of patients undergoing radical hysterectomy for cervical cancer from 2010 to 2016 was identified. Patients with stage IB1 cervical cancer were included and were grouped by ARH vs. RRH. Tumor characteristics, perioperative complications, recurrence rate, progression-free survival (PFS), and overall survival (OS) were compared between groups. Results105 patients were identified; 56 underwent ARH and 49 underwent RRH. Those who had ARH were more likely to have lesions that were ≥2 cm (62% vs. 39%, p = 0.02) and that were higher grade (p = 0.048). Other tumor characteristics were similar between groups. There was no difference in perioperative complication rates between groups. Additionally, there were no differences in recurrence risk (RR) (14% vs. 24%, p = 0.22), progression-free survival (PFS) (p = 0.28), or overall survival (OS) (p = 0.16). However, in those with tumors ≥2 cm there was a higher risk of recurrence in the overall cohort (30% vs. 8%, p = 0.006), and a shorter PFS in the RRH group (HR 0.31, p = 0.04). On multivariate analysis patients that underwent ARH or had tumors < 2 cm had a lower likelihood of recurrence (HR 0.38, p = 0.04; HR 0.175, p = 0.002) and death (HR 0.21, p = 0.029; HR 0.15, p = 0.02). ConclusionPerioperative morbidity was similar between those undergoing ARH vs. RRH for IB1 cervical cancer. Patients with tumors ≥ 2 cm undergoing RRH had a shorter PFS compared to ARH. On multivariate analysis, RRH and tumor size ≥ 2 cm were independently associated with recurrence and death in this population.

Ankle fractures: What role does level of insurance play in recovery and outcomes?

Introduction A number of factors including socioeconomic status have been correlated with post-operative outcomes in orthopedic trauma. The objective of this study is to compare post-operative courses and patient-reported outcomes following operatively managed ankle fractures taking into account a patient's level of insurance coverage. Methods A retrospective cohort study was performed at a single level I trauma center. Patients were identified by billing code for operative intervention of ankle fractures (OTA 44) from January 2014 to January 2015. Study outcomes included narcotic refills, compliance with follow-up visits, visual analog scale (VAS) pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) survey data, and perioperative complication rates. Statistical analysis included mean comparison between insurance groups and multivariate regression modeling. Results From January 2014 to January 2015, 209 patients met the inclusion criteria (45 patients under/uninsured vs. 164 fully insured). No differences were found amongst demographic data or fracture characteristics. The underinsured group had a higher average number of narcotic prescriptions (2.6 refills vs. 1.5 refills, p &lt; 0.05). The underinsured group also demonstrated a significantly greater number of missed post-operative clinic visits (0.8 vs. 0.3 visits p &lt; 0.05); the total number of post-operative visits were similar (6.4 vs. 6.9, p = 0.38). At one-year follow-up, the underinsured group had higher pain scores (VAS 3.8 vs. 2.1, p &lt; 0.05), and significantly worse PROMIS scores with respect to mood (54 vs. 49.1, p &lt; 0.05), pain (59.6 vs. 55.5, p &lt; 0.05), and functional outcomes (38 vs. 44.7, p &lt; 0.05). There was no difference in perioperative complication rates. Multivariate regression modeling found insurance (p &lt; 0.05), age (p &lt; 0.05), and smoking (p &lt; 0.05) to be significant determinants of post-operative outcomes. Conclusion Despite similar demographic and fracture characteristics, patients with decreased insurance coverage demonstrated higher narcotic requirements and missed more appointments. They had worse subjective and objective outcomes. As physician reimbursement becomes increasingly dependent on outcomes, further understanding of the psychosocial factors of this subset of patients is needed to establish realistic expectations and identify avenues for further intervention.

En bloc resection and vaporization techniques for the treatment of bladder cancer

Modifications in resection techniques may overcome obvious limitations of conventionally performed transurethral resection (e. g., tumor fragmentation) of bladder tumors or provide an easier patient treatment algorithm (e. g., tumor vaporization). The present review article summarizes the current literature in terms of en bloc resection techniques, histopathological quality, complication rates, and oncological outcomes. Aseparate data search was performed for en bloc resection (ERBT, n = 27) and vaporization (n = 15) of bladder tumors. In most cases, ERBT is performed in acircumferential fashion. Alternatively, ERBT may be performed by undermining the tumor base via antegrade application of short energy impulses. Based on high rates of detrusor in specimens of ERBT (90-100%), abetter histopathological quality is assumed. Significant differences in perioperative complication rates have not been observed, although obturator-nerve-based bladder perforations are not seen when laser energy is used. There is anonstatistically significant trend towards lower recurrence rates in ERBT groups. Tumor vaporization may provide aless invasive technique for older patients with recurrences of low-risk bladder cancer. It can be performed in an outpatient setting. ERBT may provide better histopathological quality. Tumor vaporization is performed in health care systems where reimbursement is adequate.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review.

Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

Peri-operative complications of lumbar spine surgery in patients over eighty five years of age: a retrospective cohort study.

To compare peri-operative complication rates in ≥ 85-year-old patients who underwent decompression surgery with or without instrumented fusion for degenerative disorders. This study involved 907 patients who underwent lumbar spine surgery for degenerative disorders between January 2006 and June 2012. Of these, 33 patients (3.6% of the entire population) were over 85years of age (85-94years). Decompression-alone and instrumentation groups were compared in terms of comorbidities, American Society of Anesthesiologists (ASA)-physical status (PS) class, peri-operative complications, and Japanese Orthopedic Association (JOA) scores. Thirty-three ≥ 85-year-old patients underwent surgery. All were ASA-PS class 2 (94%) or 3. The decompression-alone (n = 19) and instrumentation (n = 14) groups did not differ in comorbidity (95 vs. 100%, P = 0.383) or ASA-PS class (P = 0.561). Both exhibited improved JOA scores (decompression-alone: 13.4/29 to 22.7/29; instrumentation: 8.6/29 to 17.9/29; P = 0.9068) and had similar peri-operative complication rates (21.0 vs. 28.5%, P = 0.374). Although instrumentation is considered more invasive than decompression, we detected no statistically significant differences in peri-operative complication rates between these two types of surgery in ≥ 85-year-old patients. Surgeons should perform instrumentation even in the patients over 85years with ASA class 3 or less.

Risk Factors for Readmissions Following Anterior Lumbar Interbody Fusion.

Retrospective study of prospectively collected data. To analyze the incidence and risk factors for readmissions following anterior lumbar interbody fusion. No study has yet reported readmission rates for a specific lumbar surgical approach. There is evidence to indicate differences in perioperative complication rates between anterior versus posterior lumbar interbody fusion techniques, which may translate into differences in readmission rates. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent anterior lumbar interbody fusion. Patients were separated into groups of those with and without 30-day readmissions. Univariate analysis and multivariate logistic regression were used to analyze the effect of different risk factors on 30-day readmissions. Multivariate analysis showed that morbid obesity (odds ratio 15.6, P = 0.002) and alcohol use (odds ratio 16.9, P = 0.004) independently predicted unplanned 30-day readmission. Sex, pulmonary comorbidity, cardiac comorbidity, and steroid use were not found to be significant independent predictors of unplanned 30-day readmission in anterior lumbar interbody fusion. Adult patients undergoing anterior lumbar interbody fusion who were morbidly obese and had history of alcohol use are at increased risk for 30-day readmissions. Future studies should look to directly compare readmission rates and risk factors between alternative lumbar interbody surgical approaches with longer follow-up and more clinical and radiological parameters investigated. 3.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery.

Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93). Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

On the Question of Ethnicity and Its Impact on IBD-Related Outcomes

The global incidence of inflammatory bowel disease (IBD) has risen steadily over the last half century [1]. Previously considered a disease which predominantly afflicted Caucasians in industrialized countries, IBD is being increasingly reported in developing countries as they become ‘‘Westernized,’’ supporting the importance of environmental factors in disease pathogenesis [1, 2]. Moreover, rates of IBD among immigrant and minority populations in Canada and several western European countries are rising [2, 3]. Though population-based studies in the United States are lacking, one recent study utilizing the National Inpatient Sample (a large nationally-representative database of hospital admissions), demonstrated a temporal increase in non-white minority patients hospitalized for IBD over the last decades [4]. Within the United States, Hispanics are amongst the largest and fastest-growing minority groups, currently accounting for 16 % of the US population. Data regarding ethnic variations of disease epidemiology and phenotype amongst Hispanic IBD patients have been limited, with available literature inconsistent. For instance, there is conflicting data on whether Hispanics have higher or lower rates of Crohn’s disease [5–7], perianal complications [6, 8], and extraintestinal manifestations [5–7], when compared to Caucasians. This variability of findings is probably due to the genetic heterogeneity of Hispanics in the United States, which can include European (Spanish and Portuguese), Caribbean, and Native-American ancestry. Caribbean Hispanics are often categorized as Black (African descent) or White (European) races. With regard to treatment and outcome disparities amongst Hispanics, the current literature highlights the difficulty of separating ethnic-based differences in disease course with issues of access to care. Several retrospective studies of underserved cohorts in safety-net hospitals have suggested a smaller proportion of Hispanic IBD patients, compared to Caucasians, are prescribed immunomodulator and biologic therapy for their disease [5, 7]. Moreover, Hispanics appear to be less likely to undergo surgery for UC and Crohn’s, based on two studies utilizing the National Inpatient Sample [8, 9]. Nevertheless, patients with Medicaid were also less likely to undergo surgery than patients with private insurance, suggesting a potential contribution from socioeconomic factors. Given these apparent treatment disparities, one might suspect that Hispanic IBD patients would have poorer outcomes. In particular, surgical outcomes would be expected to underscore ethnic disparities amongst the sickest IBD patients, given surgery is reserved for medically-refractory disease or disease complications (strictures, fistulas, neoplasia). In this month’s Digestive Diseases and Sciences, Dr. Yarur and colleagues report on their findings of surgical outcomes amongst Hispanics compared to non-Hispanics [10]. To date, this is the first study evaluating ethnic differences in perioperative complication rates of IBD-related surgery. Importantly, the authors sought to control for access to care issues by comparing Hispanic and non-Hispanic patients within a single safety-net health care system (Miami-Dade County) and including only patients who received regular gastroenterological care for at least 6 months prior to their surgery. Socioeconomic differences were thought less likely, C. Hwang Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA, USA

Comparison of outcomes following endovascular repair of abdominal aortic aneurysms based on size threshold

Size threshold for operative repair of abdominal aortic aneurysms (AAAs) has been determined based on risks and outcomes of open repair vs surveillance. The influence of endovascular aneurysm repair (EVAR) on this threshold is less established. The purpose of this study is to determine whether long-term outcomes following EVAR are affected by maximum diameter at the time of treatment. Patients undergoing EVAR with modular stent grafts from 2000 to 2011 were identified from a prospectively maintained database and stratified by maximum aortic diameter at the time of repair: small (4.0-4.9cm), medium (5.0-5.9cm), and large (≥6.0cm). Comparisons of demographics, indications for repair, perioperative complications, and long-term outcomes were made using analysis of variance, χ(2), and Kaplan-Meier plots. Seven hundred forty patients were identified: 157 (21.2%) small, 374 (50.5%) medium, and 209 (28.2%) large. Patients differed by mean age (69.3± 8.09, 71.7± 8.55, and 73.6± 8.77years for small, medium, and large, respectively; P< .001), coronary artery disease (42% small, 57% medium, 51.2% large; P= .01), prior coronary angioplasty (14.6% small, 18.2% medium, 9.6% large; P= .02), congestive heart failure (5.7% small, 15.2% medium, 19.6% large; P= .01), prior vascular surgery (7% small, 15.8% medium, 10% large; P= .016), and chronic obstructive pulmonary disease (21% small, 27% medium, 33% large; P= .038). Small AAAs were more frequently symptomatic (19.7% small, 7.5% medium, 8.1% large; P< .001). There was no difference in perioperative complication rates (P=.399), expansion ≥5mm (2.6% small, 5.6% medium, 7.2% large; P= .148), or all-type endoleak (40.8% small, 41.7% medium, 44.5% large; P= .73). Small AAAs developed fewer type I endoleaks (5.1% vs 6.95% medium and 14.8% large; P= .001). Compared with small AAAs, both medium (P= .39) and large (P< .001) required secondary intervention more frequently, with hazard ratios of 2.32 (95% confidence interval, 1.045-5.156) and 4.74 (95% confidence interval, 2.115-10.637), respectively. Ten-year survival was 72%, 63.1%, and 49.8% in the small, medium, and large groups, respectively (P< .001) with one rupture-related death after EVAR in the large group. All-cause mortality differed among the 75- to 84-year-old patients (30.4% small, 51.6% medium, 55.7% large; P= .017). EVAR for small AAAs shows improved long-term outcomes than for age-matched patients with larger aneurysms.

Comparison of Long-term Outcomes Following Endovascular Repair of Abdominal Aortic Aneurysms Based on Size Threshold

Size threshold for operative repair of abdominal aortic aneurysms (AAA) has been determined based on risks and outcomes of open repair vs surveillance. The influence of endovascular repair (EVAR) on this threshold is less established. The purpose of this study is to determine whether long-term outcomes of EVAR are affected by maximum diameter at time of treatment. All patients who underwent EVAR with modular stent grafts between January 2000 and December 2011 at a single academic institution were identified from a prospectively maintained database. Patients were stratified based on maximum aortic diameter at time of repair: small (4.0-4.9 cm), medium (5.0-5.9 cm), and large (6.0 cm). Comparisons of demographics, indications for repair, and perioperative complications were made among the groups. Long-term follow-up was reviewed for expansion of the native aneurysm sac 5 mm, secondary intervention involving the native aneurysm or stent graft, and all-cause mortality. Statistical analyses were made using analysis of variance, χ2, and Kaplan-Meier plots. During the study period, 740 patients underwent EVAR with modular stent grafts: 157 small (21.2%), 374 medium (50.5%), and 209 large (28.2%). Preoperative patient characteristics were similar among the groups with exception to mean age (69.3 ± 8.09, 71.7 ± 8.55, and 73.6 ± 8.77 years for small, medium, and large, respectively; P < .001), history of coronary artery disease (42% small, 57% medium, 51.2% large; P = .01), prior coronary angioplasty (14.6% small, 18.2% medium, 9.6% large; P = .02), congestive heart failure (5.7% small, 15.2% medium, 19.6% large; P = .01), prior vascular surgery (7% small, 15.8% medium, 10% large; P = .016), and chronic obstructive pulmonary disease (21% small, 27% medium, 33% large; P = .038). Clinical classification differed significantly as a larger percentage of small AAAs were symptomatic (19.7% small, 7.5% medium, 8.1% large; P < .001). No difference in perioperative complication rates (P = .399) or all-type endoleak at any surveillance visit (40.8% small, 41.7% medium, 44.5% large; P = .73) was observed among the groups. However, the small AAA group developed fewer type I endoleaks (5.1% vs 6.95% medium and 14.8% large; P = .001). Aneurysm sac expansion of 5 mm was observed in 2.6% of small, 5.6% of medium, and 7.2% of large AAAs during the follow-up period but did not achieve a significant difference (P = .148). Secondary intervention rates differed significantly as 5.1% of small, 7.5% of medium, and 12.9% large AAAs required secondary intervention (P = .018). In direct comparison with small AAAs, medium (P = .39) and large (P < .001) groups both required secondary intervention more frequently, with hazard ratios of 2.32 (95% confidence interval, 1.045-5.156) and 4.74 (95% confidence interval, 2.115-10.637), respectively. Overall 10-year survival was 72% in the small, 63.1% in the medium, and 49.8% in the large group (P < .001) with no known AAA-related deaths. Age-adjusted all-cause mortality differed significantly among the group aged 75 to 84 years (30.4% small, 51.6% medium, 55.7% large; P = .017). EVAR for small AAAs demonstrates improved long-term outcomes when compared with EVAR for medium and large AAAs. These data suggest that EVAR for AAAs ranging from 4 to 5 cm may have better outcomes than EVAR for age-matched patients with larger aneurysms.

Partial Nephrectomy for T1b Renal Cell Carcinoma: A Safe and

Partial Nephrectomy for T1b Renal Cell Carcinoma: A Safe and

Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample

BackgroundPrior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. ObjectiveAssess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. Design, setting, and participantsAs of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). InterventionAll patients underwent RARP or ORP. MeasurementsWe compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score–matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Results and limitationsOf 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score–matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28–0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31–0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77–0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26–0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. ConclusionsRARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.