Open Colectomy Research Articles

Long-term oncologic outcomes of laparoscopic surgery for splenic flexure colon cancer are comparable to conventional open surgery

PurposeFew studies about laparoscopic surgery for splenic flexure colon cancer have been published. This study aims to compare the short- and long-term outcomes of laparoscopic surgery for splenic flexure colon cancer with those of conventional open surgery.MethodsFrom January 2004 to December 2010, 51 consecutive patients who underwent curative resection for stages I–III splenic flexure colon cancer were enrolled. Thirty-three patients underwent laparoscopy-assisted colectomy, while 18 patients underwent conventional open colectomy. Short- and long-term outcomes of the 2 groups were compared.ResultsThere were no differences in baseline characteristics, intra- and postoperative complications. The laparoscopy group showed longer operation time (median [interquartile range, IQR]: 295.0 [255.0–362.5] minutes vs. 180.0 [168.8–206.3] minutes, P < 0.001). In the laparoscopy group, return of bowel function was faster (median [IQR]: 3 [2–4] vs. 4 [3–5], P = 0.007) and postoperative hospital stay was shorter (median [IQR]: 9 [8–11] vs. 10.5 [9–19], P = 0.026). There were no statistically significant differences in overall survival rate (84.3% vs. 76.0%, P = 0.560) or disease-free survival rate (93.8% vs. 74.5%, P = 0.078) between the 2 groups.ConclusionLaparoscopic surgery for splenic flexure colon cancer has better short-term outcomes than open surgery, as well as acceptable long-term outcomes. Laparoscopic surgery can be a safe and feasible alternative to conventional open surgery for splenic flexure colon cancer.

Laparoscopic colectomy for cancer: Improved compliance with guidelines for chemotherapy and survival

Laparoscopic surgery for colon cancer has been demonstrated in clinical trials to have short-term benefits when compared to the open surgical approach. Guidelines of the National Comprehensive Cancer Network recommend that patients with stage III or high-risk stage II colon cancer undergo adjuvant chemotherapy. We hypothesized that laparoscopic colectomy is associated with increased compliance to recommendations for chemotherapy, a lesser time to start of chemotherapy, and increased overall survival. The National Cancer Data Base was queried to identify patients with stage III or high-risk stage II colon cancer (T4, positive margins, <12 lymph nodes, or high tumor grade) diagnosed 2010-2012. Patients were divided into laparoscopic colectomy and open colectomy groups. Intent-to-treat analysis was used with converted cases included in the laparoscopic colectomy group. Rates of receiving adjuvant chemotherapy, time from diagnosis and date of operation to start of chemotherapy, and overall survival were compared. A total of 48,257 patients were included for analysis; 18,801 patients underwent laparoscopic colectomy and 29,456 underwent open colectomy. Laparoscopic colectomy patients received adjuvant chemotherapy at a somewhat greater rate than open colectomy (66.2% vs 59.4%, P<.01). Among patients who received chemotherapy, mean time to start of chemotherapy after definitive resection was somewhat less for laparoscopic colectomy than open colectomy (48.7 vs 52.7days, P<.01). Two-year overall survival was greater for laparoscopic colectomy than open colectomy (81.9% vs 73.2%, P<.01). Compared to open colectomy, laparoscopic colectomy is associated with somewhat greater rates of compliance with guidelines for adjuvant chemotherapy for stage III and high-risk stage II colon cancer, as well as a slightly lesser time to start of chemotherapy and improved overall survival.

Risk factors for post-colectomy adhesive small bowel obstruction.

The purpose of this study was to assess the risk factors for adhesive small bowel obstruction (SBO) following colectomy for colorectal cancer. In this retrospective study we analyzed 284 patients who underwent surgery for colorectal cancer at the Department of Surgery University Clinical Center Tuzla in the period from 1st January 2009 until 31st December 2014. All patients underwent open colectomy. The length of follow up was from 6 months to 6 years (median follow up 3 years and 6 months). The study included all patients who underwent surgery due to colon cancer. The study excluded patients with postoperative small bowel obstruction after colon cancer surgery with different comorbidities. In the analyzed sample of 284 patients, a small bowel obstruction occurred in 13.7% patients after surgery for colon cancer. The highest correlation of risk factors and the occurrence of postoperative small bowel obstruction after colectomy for colorectal cancer in multivariate regression analysis was found to be for Tumor-Node-Metastasis ≥3 (or =3.680), and postoperative complications (or =30.683). Postoperative SBO have many causes, but in this study the highest risk factors were the Tumor-Node-Metastasis ≥3, and postoperative complications.

Colon Cancer Surgery: A Retrospective Study Based on a Large Administrative Database.

Laparoscopic colectomy (LC) for colon cancer is considered as safe and effective as open colectomy. It has many benefits in terms of postoperative pain, length of hospital stay, and esthetic results. There is evidence in the United States of a positive trend in the proportion of oncologic patients undergoing LC. Our aim is to confirm this trend in Europe and identify factors associated with a greater use of LC. A retrospective cohort study based on hospital discharge records (HDR) collected from 2008 to 2013 in a north-eastern Italian region (Veneto). The sample included all HDR with colon cancer as their principal or secondary diagnosis, treated with partial or total colectomy. To establish the overall regional trend of LC, we standardized cases by age, referring to the number of procedures performed by age group in 2010. We calculated the annual percent change from the slope of the regression model over a given time interval. Out of 14,085 colectomies, 29% were completed laparoscopically. The age-adjusted rates of LC by year ranged from 23.8% (2008) to 36.0% (2013). The mean annual increase in the LC rate was 2.4% overall (P<0.001). Factors associated with a higher proportion of LC were younger age (39% LC in patients below 65 y vs. 25% in those above 65 y), public hospitals (odds ratio: 1.71; 95% confidence interval, 1.51-1.94; P<0.05) and elective admissions (odds ratio: 4.19; 95% confidence interval, 3.76-4.67; P<0.05). Although the proportion of LC is growing, there are factors that influence the likelihood of this procedure being conducted. Future efforts to extend the use of LC to all eligible patients and avoid disparities should target both surgeons and patients, promoting the development and dissemination of appropriate guidelines.

Effect of Flexible Duty Hour Policies on Length of Stay for Complex Intra-Abdominal Operations: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis

Changes to resident duty hour policies in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial could impact hospitalized patients' length of stay (LOS) by altering care coordination. Length of stay can also serve as a reflection of all complications, particularly those not captured in the FIRST trial (eg pneumothorax from central line). Programs were randomized to either maintaining current ACGME duty hour policies (Standard arm) or more flexible policies waiving rules on maximum shift lengths and time off between shifts (Flexible arm). Our objective was to determine whether flexibility in resident duty hours affected LOS in patients undergoing high-risk surgical operations. Patients were identified who underwent hepatectomy, pancreatectomy, laparoscopic colectomy, open colectomy, or ventral hernia repair (2014-2015 academic year) at 154 hospitals participating in the FIRST trial. Two procedure-stratified evaluations of LOS were undertaken: multivariable negative binomial regression analysis on LOS and a multivariable logistic regression analysis on the likelihood of a prolonged LOS (>75th percentile). Before any adjustments, there was no statistically significant difference in overall mean LOS between study arms (Flexible Policy: mean [SD] LOS 6.03 [5.78] days vs Standard Policy: mean LOS 6.21 [5.82] days; p= 0.74). In adjusted analyses, there was no statistically significant difference in LOS between study arms overall (incidence rate ratio for Flexible vs Standard: 0.982; 95% CI, 0.939-1.026; p= 0.41) or for any individual procedures. In addition, there was no statistically significant difference in the proportion of patients with prolonged LOS between study arms overall (Flexible vs Standard: odds ratio= 1.028; 95% CI, 0.871-1.212) or for any individual procedures. Duty hour flexibility had no statistically significant effect on LOS in patients undergoing complex intra-abdominal operations.

Racial disparities in the use of laparoscopic surgery to treat colonic diverticulitis Are not fully explained by socioeconomics or disease complexity

BackgroundSeveral studies have demonstrated favorable outcomes for laparoscopic surgery over open surgery for the treatment of diverticular disease. This study was designed to analyze the relationship between race, socioeconomic status and the use of laparoscopy to address diverticulitis. MethodsA retrospective analysis of 53,054 diverticulitis admissions was performed using data from the 2009–2013 National Inpatient Sample (NIS). The primary outcome was the use of laparoscopic versus open colectomy. Bivariate analysis and multivariable logistic regression were used to determine the raw and adjusted odds by race, insurance status, and median household income. ResultsOverall, 41.6% of colectomies involved the use of laparoscopy. Black patients were 19% less likely than White patients to undergo laparoscopic surgery. Hispanic patients were no more or less likely to undergo laparoscopic colectomy. Lacking private insurance was a strong predictor of undergoing open surgery. Lower income patients were 33% less likely to receive minimally invasive colectomies. ConclusionsThese results demonstrate disparities in surgical treatment. Further research is warranted to understand and ameliorate treatment differences which can contribute to outcome disparities.

A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits.

The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery. A Truven MarketScan® claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region. A total of 4615 colectomies were included-2054 (44.5%) open and 2561 (55.5%) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p<0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9% open vs. 2.0% MIS, p<0.001), higher overall complications (52.8% open vs. 32.3% MIS, p<0.001), higher colorectal-specific complications (32.5% open vs. 17.9% MIS, p<0.001), longer LOS (6.39 open vs. 4.44days MIS, p<0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p<0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p=0.0013), higher average readmission costs ($3055 vs. $2,514; p=0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p=0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution. In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.

Evaluation of Open vs Laparoscopic Colectomy Resections in Stage IV Colon Cancer Patients: American College of Surgeons NSQIP Analysis

Evaluation of Open vs Laparoscopic Colectomy Resections in Stage IV Colon Cancer Patients: American College of Surgeons NSQIP Analysis

Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy

BackgroundUrgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy. MethodsThe University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality. ResultsThe overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84). ConclusionsMortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Open Colectomies.

Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections. Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies. This was a retrospective study using the Premier Perspective database. Included were patient hospitalizations nationwide from January 2006 to December 2013. A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study. Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery). Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63-0.82)), ertapenem (OR = 0.65 (95% CI, 0.58-0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49-0.64)), and "other" (OR = 0.81 (95% CI, 0.73-0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings. The study was limited by its lack of detailed clinical information in the billing data set used. In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.

Iatrogenic superior mesenteric vein injury: the perils of high ligation.

The purpose of this review is to highlight the perils and pitfalls associated with high vascular ligation during right colectomies for adenocarcinoma and to identify the various mechanisms of injury to the superior mesenteric vein (SMV) and its tributaries. This is a retrospective chart review of 304 right colectomies (159 open and 145 laparoscopic) performed over a period of 10years (1 June 2006-31 May 2016) for right-sided colonic adenocarcinoma in an academic medical center. During a 10-year study period, we encountered five cases in which significant damage to the SMV and its tributaries occurred. This accounts for a total of 1.6% of all right colectomies performed for colonic adenocarcinoma. Iatrogenic superior mesenteric vein injury is a rare, severe, and underreported complication of both open and laparoscopic right colectomy for colonic adenocarcinoma. We identified several mechanisms of injury such as anatomic misperception, excessive traction and pulling on the venous system, extensive tumor involvement of the mesentery, and uncontrolled suturing attempts at hemostasis. We believe that increased awareness of this complication with profound understanding of vascular anatomy and the different mechanisms of injury will allow surgeons to avoid this often devastating complication.

Right Versus Left-Sided Colectomies: A Comparison of Outcomes

Surgeons often consider that a right colectomy (RC) carries less risk than a left or sigmoid colectomy (L/SC). Our aim was to compare outcomes between RC and L/SC. Review of the Carolinas Medical Center National Surgical Quality Improvement Program data from 2013 to February 2015 was performed. Procedures were categorized as RC Versus L/SC based on current procedural terminology codes for both open and laparoscopic colectomies. Demographics and minor and major complications were evaluated using standard statistical methods. A total of 164 RC and 211 L/SC were studied. RC patients were older (63.9 ± 14.2 vs 59.4 ± 13.0, P < 0.001). Patients undergoing RC had more comorbidities, and 64.6 per cent had an American Society of Anesthesiologist (ASA) Class III or above Versus 51.7 per cent of those undergoing L/SC (P = 0.02). RC had significantly higher rates of postop urinary tract infection (7.3% vs 2.8%, P = 0.04) and postop transfusions (P = 0.01). Average length of stay was longer for RC (10.1 ± 8.6 days vs 8.3 ± 7.0 days, P < 0.01). After controlling for ASA class, preoperative hematocrit and surgical technique (lap Versus open), multivariate analysis indicated that there were no longer any significant differences in outcomes between RC and L/SC. There were no differences between the group complications including superficial or deep surgical site infections, anastomotic leak, myocardial infarction (MI), pneumonia, or 30-day mortality. RC patients tended to be sicker and had more medical complications postop with initial evaluation of the data. However, when controlling for ASA, hematocrit, and techniques, there were no differences in complications when RC was compared to L/SC. The belief that L/SC has a higher rate of complications compared to RC is not supported.

Hand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort

BackgroundPerioperative outcomes of patients who underwent hand-assisted colorectal laparoscopic (HALS) vs open colectomy were compared using recently released procedure-targeted database. MethodsReview was conducted using the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. Patients were classified into 2 groups according to final surgical approach: HALS vs open (planned). Groups were matched (1:1) based on age, gender, body mass index, surgical procedure, diagnosis, American Society of Anesthesiologists score, and wound classification. Multivariate logistic regression analysis was conducted for group comparison. ResultsOf 7,303 patients, 1,740 patients were matched in each group. Open group had higher proportion of patients with preoperative dyspnea (P = .01), ascites (P = .01), weight loss (P < .001), smoking history (P = .04), and increased work relative value units (P < .001). After adjusting for difference in baseline comorbidities, overall morbidity, superficial, deep, and organ-space surgical site infection, urinary tract infection, ileus, reoperation, readmission, and hospital stay were significantly higher in open group (P < .05). ConclusionsNational Surgical Quality Improvement Program targeted-data demonstrated several advantages of HALS compared with open colonic resection including shorter hospital stay and lower complication rate. Further adoption of HALS technique as a bridge to straight laparoscopy or tool in difficult cases can positively impact the short-term outcomes after colectomy when compared with open technique.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery.

BackgroundEvidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients’ insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians.MethodUsing a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round.Results Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice.ConclusionMultidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Risk of anastomotic leak after laparoscopic versus open colectomy.

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions. The 2012-2013 ACS-NSQIP targeted colectomy data were queriedfor all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak. Of 23,568 patients, 3.4% developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8% (n=425) and open surgery, 4.5% (n=378, p<0.0001). Patients who developed a leak were more likely to die within 30days of surgery (5.7 vs. 0.6%, p<0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63years, p=0, p=0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p<0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95% CI 0.58-0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak. Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

Biobanking of Fresh-Frozen Human Adenocarcinomatous and Normal Colon Tissues: Which Parameters Influence RNA Quality?

Medical research projects become increasingly dependent on biobanked tissue of high quality because the reliability of gene expression is affected by the quality of extracted RNA. Hence, the present study aimed to determine if clinical, surgical, histological, and molecular parameters influence RNA quality of normal and tumoral frozen colonic tissues. RNA Quality Index (RQI) was evaluated on 241 adenocarcinomas and 115 matched normal frozen colon tissues collected between October 2006 and December 2012. RQI results were compared to patients’ age and sex, tumor site, kind of surgery, anastomosis failure, adenocarcinoma type and grade, tumor cell percentage, necrosis extent, HIF-1α and cleaved caspase-3 immunohistochemistry, and BRAF, KRAS and microsatellites status. The RQI was significantly higher in colon cancer tissue than in matched normal tissue. RQI from left-sided colonic cancers was significantly higher than RQI from right-sided cancers. The RNA quality was not affected by ischemia and storage duration. According to histological control, 7.9% of the samples were unsatisfactory because of inadequate sampling. Biobanked tumoral tissues with RQI ≥5 had lower malignant cells to stromal cells ratio than samples with RQI <5 (p <0.05). Cellularity, necrosis extent and mucinous component did not influence RQI results. Cleaved caspase-3 and HIF-1α immunolabelling were not correlated to RQI. BRAF, KRAS and microsatellites molecular status did not influence RNA quality. Multivariate analysis revealed that the tumor location, the surgical approach (laparoscopy versus open colectomy) and the occurrence of anastomotic leakage were the only parameters influencing significantly RQI results of tumor samples. We failed to identify parameter influencing RQI of normal colon samples. These data suggest that RNA quality of colonic adenocarcinoma biospecimens is determined by clinical and surgical parameters. More attention should be paid during the biobanking procedure of right-sided colon cancer or laparoscopic colectomy specimen. Histological quality control remains essential to control sampling accuracy.

Surgeon-Level Variation in Postoperative Complications

BackgroundVariation in surgical outcomes is often attributed to patient comorbidities and the severity of underlying disease, but little is known about the extent of variation in outcomes by surgeon and the surgeon factors that are associated with quality. MethodsUsing the Maryland Health Services Cost Review Commission database, we evaluated risk-adjusted postoperative events by surgeon. Operations studied were elective laparoscopic and open colectomy procedures for colon cancer performed over a 2-year period (July 2012–September 2014). Postoperative events were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeons performing fewer than ten procedures during the study period were excluded. Logistic regression and post-estimation were used to calculate an observed-to-expected (O/E) ratio of postoperative complications for each surgeon, adjusting for patient and surgeon characteristics. ResultsA total of 2525 patients underwent an elective colectomy during the study period by 276 surgeons at 44 hospitals. Postoperative complications varied more by surgeon (range 0 to 30.0 %) than by hospital (range 0 to 18.2 %). Surgeon-level use of laparoscopic surgery to perform colectomy ranged from 0 to 100 %. After risk adjustment with patient factors, surgeon experience, surgeon medical school, surgeon gender, and annual surgeon colectomy volume were not associated with postoperative complications. Surgeon use of laparoscopy was the strongest predictor of lower complications (vs fourth quartile of surgeons, first quartile OR = 0.47 (0.26–0.85); second quartile OR = 0.41 (0.22–0.73); and third quartile OR = 0.84 (0.52–1.36). ConclusionsQuality metrics in health care have been measured at the hospital level, but a greater quality improvement potential exists at the surgeon level. Awareness of this variation could better inform patients undergoing elective surgery and their referring physicians.

Short-term outcomes of minimally invasive versus open colectomy for colon cancer

BackgroundLaparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer. Materials and methodsPatients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach—open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups. ResultsA total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001). ConclusionsThis retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.

Variations in the Use of Perioperative Multimodal Analgesic Therapy.

Practice guidelines for perioperative pain management recommend that multimodal analgesic therapy should be used for all postsurgical patients. However, the proportion of patients who actually receive this evidence-based approach is unknown. The objective of this study was to describe hospital-level patterns in the utilization of perioperative multimodal analgesia. Data for the study were obtained from the Premier Research Database. Patients undergoing below-knee amputation, open lobectomy, total knee arthroplasty, and open colectomy between 2007 and 2014 were included in the analysis. Patients were considered to have multimodal therapy if they received one or more nonopioid analgesic therapies. Mixed-effects logistic regression models were used to estimate the hospital-specific frequency of multimodal therapy use while adjusting for the case mix of patients and hospital characteristics and accounting for random variation. The cohort consisted of 799,449 patients who underwent a procedure at 1 of 315 hospitals. The mean probability of receiving multimodal therapy was 90.4%, with 95% of the hospitals having a predicted probability between 42.6 and 99.2%. A secondary analysis examined whether patients received two or more nonopioid analgesics, which gave an average predicted probability of 54.2%, with 95% of the hospitals having a predicted probability between 9.3 and 93.2%. In this large nationwide sample of surgical admissions in the United States, the authors observed tremendous variation in the utilization of multimodal therapy not accounted for by patient or hospital characteristics. Efforts should be made to identify why there are variations in the use of multimodal analgesic therapy and to promote its adoption in appropriate patients.

Su1765 A Comparison of Lymph Node Harvest Following Emergent Laparoscopic Versus Open Colectomy for Colon Cancer: Results From the ACS-NSQIP Database

Su1765 A Comparison of Lymph Node Harvest Following Emergent Laparoscopic Versus Open Colectomy for Colon Cancer: Results From the ACS-NSQIP Database