Aim
Up to 10% of patients who undergo nonurological abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate identification of the ureter is common, it ...does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance that does not rely on tactile feedback is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic‐assisted colorectal surgery.
Method
Patients undergoing adjunctive ureteral identification during robotic‐assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5‐Fr open‐ended ureteral catheter was inserted up to 20 cm and used to inject 5 ml of 2.5 mg/ml ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near‐infrared laser fluorescence technology (Firefly®).
Results
Successful ICG‐enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic‐assisted colorectal surgery. The median ICG instillation time was 11.5 min (range 4–21 min) and the median operative time with ICG visualization was 489 min (8 h 9 min) range 268–738 min (4 h 28 min–12 h 18 min). No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration.
Conclusion
Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic‐assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic‐assisted operations.
Background
Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of ...anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries.
Methods
Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS).
Results
The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312;
p
< 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (
n
= 62,292) where cost was $30,885 higher ($43,918 vs. $13,033;
p
< 0.0001) and LOS was 15 days longer (17 vs. 2 days;
p
< 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured.
Conclusion
Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.
Background
Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency ...colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large‐scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology.
Methods
LaCeS was designed as a prospective, multicentre, single‐blind, parallel‐group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery.
Results
A total of 64 patients were recruited across five centres. The overall mean steady‐state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health‐related quality‐of‐life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30‐day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open
arm.
Conclusion
Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 (
http://www.controlled‐trials.com).
Antecedentes
Aproximadamente 30.000 personas se someten cada año una operación de cirugía mayor urgente gastrointestinal de las cuales el 36% (~ 10.800) se realizan por patología colorrectal urgente. Aproximadamente el 14% de todos los pacientes que requieren cirugía urgente son operados mediante abordaje laparoscópico. Los objetivos del ensayo de factibilidad LaCeS (Laparoscopic versus Open Colorectal Surgery in the Acute Setting; Cirugía Colorrectal Laparoscópica versus Abierta en Urgencias) fueron evaluar la factibilidad, seguridad y aceptabilidad de realizar un ensayo clínico aleatorizado definitivo a gran escala de fase III comparando la cirugía colorrectal urgente por vía laparoscópica con el abordaje abierto.
Métodos
LaCeS se diseñó como un ensayo clínico prospectivo, multicéntrico, simple ciego, de grupos paralelos, pragmático, aleatorizado (factibilidad) con un estudio cualitativo integrado. La asignación al azar se realizó de forma centralizada y los pacientes se asignaron al azar en proporción 1:1 a cirugía laparoscópica o abierta.
Resultados
Un total de 64 pacientes fueron reclutados en 5 centros. La tasa media global estable de reclutamiento fue de 1,2 pacientes/mes. El cumplimiento inicial de los datos clínicos y de calidad de vida (HRQoL) fue del 99,8% y del 93,8%, respectivamente. La tasa de conversión de la cirugía laparoscópica a cirugía abierta fue del 39,4% (i.c. del 95%: 22,9% a 57,9%). La tasa de complicaciones postoperatorias a los 30 días fue del 27,3% (i.c. del 95%: 13,3‐45,5) para la cirugía laparoscópica y del 41,9% (i.c. del 95%: 24,6‐60,9) para la cirugía abierta.
Conclusión
La cirugía colorrectal urgente por vía laparoscópica puede tener un perfil de seguridad aceptable.
The LaCeS feasibility trial has demonstrated that it is possible to evaluate laparoscopic surgery in the emergency colorectal setting within the context of an RCT. It has also shown that it is possible to recruit to a surgical trial in the emergency setting, with good compliance to trial procedures and processes, and overall acceptability by patients and clinicians.
Nicely tied LaCeS
Background Fast-track (FT) protocols accelerate patient's recovery and shorten hospital stay as a result of the optimization of the perioperative care they offer. The aim of this review is to examine ...the latest evidence for fast-track protocols when compared with standard care in elective colorectal surgery involving segmental colonic and/or rectal resection. Materials and methods All randomized controlled trials and controlled clinical trials on FT colorectal surgery were reviewed systematically. The main end points were short-term morbidity, length of primary postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality. Quality assessment and data extraction were performed independently by two observers. Results Eleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven controlled clinical trials (CCT)), including 1,021 patients. Primary hospital stay (weighted mean difference -2.35 days, 95% confidence interval (CI) -3.24 to -1.46 days, P < 0.00001) and total hospital stay (weighted mean difference -2.46 days, 95% CI -3.43 to -1.48 days, P < 0.00001) were significantly lower for FT programs. Morbidity was also lower in the FT group. Readmission rates were not significantly different. No increase in mortality was found. Conclusions FT protocols show high-level evidence on reducing primary and total hospital stay without compromising patients' safety offering lower morbidity and the same readmission rates. Enhanced recovery programs should become a mainstay of elective colorectal surgery.
Abstract Background Specific International Classification of Diseases, Ninth Revision, codes for laparoscopic procedures introduced in 2008 allow a more accurate evaluation of laparoscopic colorectal ...surgery. Methods Using the Nationwide Inpatient Sample 2009, a retrospective analysis of surgical colorectal cancer and diverticulitis patients was conducted. Logistic regression was used to estimate odds ratios comparing the outcomes of laparoscopic, open, and converted surgery. Results A total of 121,910 patients underwent resection for cancer and diverticulitis, 35.41% of whom underwent laparoscopic surgery. Compared with open surgery, laparoscopic surgery had lower postoperative complication rates, lower mortality, shorter hospital stays, and lower costs. Compared to open surgery, laparoscopic surgery independently decreased mortality, postoperative anastomotic leak, urinary tract infection, ileus or obstruction, pneumonia, respiratory failure, and wound infection. Converted surgery was independently associated with anastomotic leak, wound infection, ileus or obstruction, and urinary tract infection. Conclusions Laparoscopic colorectal surgery has lower postoperative complications, lower mortality, lower costs, and shorter hospital stays. Conversion had higher complications compared with laparoscopy. The use of laparoscopy should increase with efforts to minimize conversion.
Background Colorectal surgery is associated with considerable morbidity and prolonged length of stay (LOS). Recognizing the need for improvement, we implemented an enhanced recovery (ER) protocol for ...all patients undergoing elective colorectal surgery at an academic institution. Study Design A multidisciplinary team implemented an ER protocol based on: preoperative counseling with active patient participation, carbohydrate loading, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, immediate postoperative feeding, and ambulation. Discharge requirements remained identical throughout. A before and after study design was undertaken comparing patients before (August 2012 to February 2013) and after implementation of an ER protocol (August 2013 to February 2014). Risk stratification was performed using the NSQIP risk calculator to calculate the predicted LOS for each patient based on 23 variables. Results One hundred and nine consecutive patients underwent surgery within the ER protocol compared with 98 consecutive historical controls (conventional). The risk-adjusted predicted LOS was similar for each group at 5.1 and 5.2 days. Substantial reductions were seen in LOS, morphine equivalents, intravenous fluids, return of bowel function, and overall complications with the ER group. There was a $7,129/patient reduction in direct cost, corresponding to a cost savings of $777,061 in the ER group. Patient satisfaction as measured by Press Ganey improved considerably during the study period. Conclusions Implementation of an ER protocol led to improved patient satisfaction and substantial reduction in LOS, complication rates, and costs for patients undergoing both open and laparoscopic colorectal surgery. These data demonstrate that small investments in the perioperative environment can lead to large returns.
Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess ...current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography.
We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age.
From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+).
Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.
Low health literacy (HL) adversely affects medical adherence and health outcomes in patients with chronic diseases. However, the association between HL and enhanced recovery after surgery (ERAS) ...adherence and postoperative outcomes has not been investigated in patients undergoing colorectal surgery.
The data of all patients from a single academic institution who underwent colorectal surgery on an ERAS pathway from January 2019 to July 2020 were prospectively collected. HL levels were assessed using the Brief Health Literacy Screen (BHLS), a proven tool that was used by surgeons after recruitment. According to the HL score, the participants were categorized into low HL (≤9 points) and high HL (10-15 points) groups. The primary outcome was ERAS adherence. Adherence was measured in 22 perioperative elements, and high adherence was defined as adherence to 17 to 22 elements. Secondary outcomes included postoperative complications, hospital length of stay (LOS), hospital charges, mortality, and readmissions.
Of the 865 eligible patients, the high HL group consisted of 329 patients (38.0%), and the low HL group contained 536 patients (62.0%). After propensity score matching (1:1), 240 unique pairs of patients with similar characteristics were selected. Patients with high HL levels had a significantly higher rate of high adherence to ERAS standards than those with low HL levels (55% vs 25.8%; adjusted P < .001). In terms of adherence to each item, high HL levels were significantly associated with higher adherence to preoperative optimization (90.8% vs 71.7%; adjusted P < .001), postoperative gum chewing (59.2% vs 44.6%; adjusted P = .01), early feeding (59.2% vs 31.3%; adjusted P < .001), and early mobilization (56.7% vs 30.4%; adjusted P < .001). In the overall study population, adjusted logistic regression analyses also showed that high HL levels were associated with a significantly increased rate of high adherence when compared with low HL levels (adjusted odds ratio OR, 3.57; 95% confidence interval (CI), 2.50-5.09; P < .001). In addition, low HL levels were associated with a significantly higher incidence of postoperative complications (32.1% vs 20.8%; P < .01), longer hospital LOS (9 interquartile range {IQR}, 7-11 vs 7 IQR, 6-9 d; P < .001), and higher hospital charges (10,489 IQR, 8995-11942 vs 8466 IQR, 7733-9384 dollar; P < .001) among propensity-matched patients. However, there were no differences in the mortality and readmission rates between the HL groups.
Low HL levels were associated with lower adherence to ERAS elements among propensity-matched patients undergoing colorectal surgery.
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