Elective laparoscopic versus open colectomy for diverticulosis: an analysis of ACS-NSQIP database. Surg Endosc. 2012;26:1837-1842. [PMID: 22258301 DOI: 10.1007/s00464-011-2142-y]

Reoperation and mortality following elective surgery for chronic and recurrent colonic diverticular disease: A nationwide population-based cohort study

PURPOSE

The ideal treatment for chronic and recurrent colonic diverticular disease (crDD) remains unresolved, partly due to lacking evidence regarding surgical safety. This study evaluated 90-day reoperation and mortality rates following elective surgery for crDD and explored predictors for reoperation and mortality.

METHODS

This national cohort study included all patients with crDD undergoing elective colonic resection or stoma formation in Denmark from 1996-2021. Outcomes were the 90-day cumulative incidence proportion (CIP) of reoperation and mortality, and predictors were explored in Cox proportional hazard models.

RESULTS

Among 35,174 patients with crDD, 3,584 (10%) underwent elective surgery. The 90-day reoperation rate was 18.0%; mortality was 1.6%. During the 25-year period, the reoperation rate declined 30%, from 19.5% to 13.8%, and mortality declined 74%, from 2.7% to 0.7%. Among 2,942 patients with colonic resection and no stoma formation, the reoperation rate due to anastomotic leak was 3.0% overall and 0.9% in the most recent years. Mortality was 18 times higher in patients aged ≥ 80 years versus those aged < 60 years (CIP 8.0% versus 0.4%). The reoperation rate was increased in patients with ≥ 4 hospital contacts or ≥ 3 admissions compared to patients with fewer contacts, while mortality was not associated with the number of hospital contacts before surgery.

CONCLUSION

Elective surgery in crDD was safe with careful patient selection. The risk of reoperation due to anastomotic leak was very low. Patients with most hospital contacts had an increased reoperation rate, supporting consideration for elective surgery early in patients with disabling diverticular disease.

Smoking and Alcohol Consumption and Risk of Incident Diverticulitis in Women

BACKGROUND & AIMS

Much of what is known about the effects of alcohol and tobacco use on diverticular disease derives from studies of asymptomatic diverticulosis or complicated diverticulitis. We examined smoking and alcohol consumption and risk of incident diverticulitis in a large cohort of women.

METHODS

We conducted a prospective study of 84,232 women in the Nurses' Health Study II (NHS II) who were 39-52 years old and without known diverticulitis at baseline in 2003. Smoking was ascertained every 2 years and alcohol use every 4 years. We used Cox proportional hazards regression to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During 1,139,660 person-years of follow up, we identified 3018 incident cases of diverticulitis. After adjustment for other risk factors, current (HR, 1.20; 95% CI, 1.04-1.39) and past smoking (HR, 1.20; 95% CI, 1.11-1.30) were associated with increased risk of diverticulitis when compared with never smokers. Women who consumed ≥30 g/d of alcohol had a multivariate HR of 1.26 (95% CI, 1.05-1.50) when compared with women who did not drink. A joint analysis of smoking and alcohol found that individuals who ever smoked and consumed ≥15 g/d of alcohol were at highest risk of diverticulitis (multivariate HR, 1.60; 95% CI, 1.16-2.21), compared with participants who never smoked and reported no alcohol use.

CONCLUSIONS

In this large prospective study of women, smoking and alcohol consumption were associated with an increased risk of incident diverticulitis. These data highlight additional modifiable risk factors for diverticulitis that may aid in prevention.

Risk Factors Associated with Postoperative Outcomes in Diverticular Disease Undergoing Elective Colectomy-A Retrospective Cohort Study from the ACS-NSQIP Database

Recommendations for elective colectomies after recovery from uncomplicated acute diverticulitis should be individualized. The kinds of associated risk factors that should be considered for this approach remain undetermined. The aim of this study was to identify the risk factors associated with postoperative outcomes in patients with diverticular disease after receiving an elective colectomy. This is a retrospective study using the multi-institutional, nationally validated database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). The patients who were diagnosed with diverticular disease and received an elective colectomy were included in our risk factor analyses. Postoperative mortality, morbidity, and overall complications were measured. Univariate and multivariate analyses were used to demonstrate the risk factors. We analyzed 30,468 patients with diverticular disease, 67% of whom received an elective colectomy. The rate of 30-day mortality was 0.2%, and superficial surgical site infection was the most common postoperative morbidity (7.2%) in the elective colectomies. The independent risk factors associated with overall complications were age ≥ 75, BMI ≥ 30, smoking status, dyspnea, hypertension, current kidney dialysis, chronic steroid use, ASA III, and open colectomy. In laparoscopic colectomy, 67.5% of the elective colectomies, the associated risk factors associated with overall complications still included age ≥ 75, smoking, hypertension, chronic steroid use, and ASA III. Identification of patient-specific risk factors may inform the decision-making process for elective colectomy and reduce the postoperative complications after mitigation of those risk factors.

Laparoscopic versus robotic-assisted, left-sided colectomies: intra- and postoperative outcomes of 683 patients

Background

Robotic-assisted colorectal surgery has gained more and more popularity over the last years. It seems to be advantageous to laparoscopic surgery in selected situations, especially in confined regions like a narrow male pelvis in rectal surgery. Whether robotic-assisted, left-sided colectomies can serve as safe training operations for less frequent, low anterior resections for rectal cancer is still under debate. Therefore, the aim of this study was to evaluate intra- and postoperative results of robotic-assisted laparoscopy (RAL) compared to laparoscopic (LSC) surgery in left-sided colectomies.

Methods

Between June 2015 and December 2019, 683 patients undergoing minimally invasive left-sided colectomies in two Swiss, high-volume colorectal centers were included. Intra- and postoperative outcome parameters were collected and analyzed.

Results

A total of 179 patients undergoing RAL and 504 patients undergoing LSC were analyzed. Baseline characteristics showed similar results. Intraoperative complications occurred in 0.6% of RAL and 2.0% of LSC patients (p = 0.193). Differences in postoperative complications graded Dindo ≥ 3 were not statistically significant (RAL 3.9% vs. LSC 6.3%, p = 0.227). Occurrence of anastomotic leakages showed no statistically significant difference [RAL n = 2 (1.1%), LSC n = 8 (1.6%), p = 0.653]. Length of hospital stay was similar in both groups. Conversions to open surgery were significantly higher in the LSC group (6.2% vs.1.7%, p = 0.018), while stoma formation was similar in both groups [RAL n = 1 (0.6%), LSC n = 5 (1.0%), p = 0.594]. Operative time was longer in the RAL group (300 vs. 210.0 min, p < 0.001).

Conclusion

Robotic-assisted, left-sided colectomies are safe and feasible compared to laparoscopic resections. Intra- and postoperative complications are similar in both groups. Most notably, the rate of anastomotic leakages is similar. Compared to laparoscopic resections, the analyzed robotic-assisted resections have longer operative times but less conversion rates. Further prospective studies are needed to confirm the safety of robotic-assisted, left-sided colectomies as training procedures for low anterior resections.

Outcomes of diverticulitis in patients with tobacco smoking: a propensity-matched analysis of nationwide inpatient sample

BACKGROUND

Recent data shows a significantly increased risk of diverticulosis among smokers. There is limited data on the association between tobacco smoking and diverticulitis. We aim to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of diverticulitis patients based on tobacco smoking status.

METHODS

A retrospective analysis was performed by utilizing the National Inpatient Sample database (2016 and 2017) and the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of diverticulitis and smoking. We assessed all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of tobacco smokers vs. nonsmokers with diverticulitis.

RESULTS

We identified 442,273 diverticulitis patients, of whom 96,864 were tobacco smokers, and 345,409 were nonsmokers. Between the two groups, in-hospital mortality was not significant (OR 1.09, 95% CI 0.38-2.6; P = 0.98). Tobacco smokers with diverticulitis have higher odds of lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.4-3.8; P = 0.01), peritonitis (OR 1.5, 95% CI 1.9-3.3; P = 0.00), intestinal obstruction (OR 1.6, 95% CI 2.8-7.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and shock requiring vasopressor (OR 1.5, 95% CI 1.2-2.2; P = 0.00). In tobacco smokers with complicated diverticulitis, there were higher odds of LGIB (OR 1.4, 95% CI 1.2-1.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and colectomy (OR 1.2, 95% CI 1.1-1.2; P = 0.00). In-hospital mortality was not significant in smokers with complicated diverticulitis (OR 1.2, 95% CI 0.78-1.9; P = 0.3).

CONCLUSIONS

In this propensity-matched analysis, there was no difference in in-hospital mortality between tobacco smokers vs. nonsmokers with diverticulitis. Smoking has been associated with an increased incidence of complications in diverticulitis with a higher length of hospital stay and resource utilization.

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease

BACKGROUND

Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes.

METHODS

The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases.

RESULTS

The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases.

CONCLUSIONS

Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.

Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery

The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Laparoscopic Approach in Colonic Diverticulitis: Dispelling Myths and Misperceptions

BACKGROUND/AIM

Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant morbidity and mortality. In this review of the literature, we aim to assess the feasibility and effectiveness of the laparoscopic approach in both elective and emergency setting of diverticular disease.

MATERIALS AND METHODS

A bibliographic search of articles was performed using the electronic database Medline from PubMed. Of 341 articles identified, 279 were excluded, resulting in 62 full-text articles for review. Our final review included 16 articles.

RESULTS

The 16 articles included in the final review consisted of 6 retrospective studies, 5 prospective studies, 2 randomized controlled trials, 1 systematic review and meta-analysis, and 2 systematic reviews. Seven articles considered elective laparoscopic sigmoid resection, 7 articles evaluated laparoscopic peritoneal lavage, and 2 articles considered emergency laparoscopic sigmoid resection for perforated diverticulitis. The elective laparoscopic approach is feasible and safe. Laparoscopic peritoneal lavage has emerged as a safe and effective minimally invasive procedure for the treatment of perforated diverticulitis. Furthermore, in selected patients, emergency laparoscopic sigmoidectomy could also be feasible for perforated diverticulitis with generalized peritonitis.

CONCLUSIONS

Laparoscopic approach can be a safe and effective option in both elective and emergency setting of diverticular disease. Large, prospective, randomized studies should be conducted to confirm these findings.

Impact of frailty on approach to colonic resection: Laparoscopy vs open surgery

AIM

To understand the influence of frailty on postoperative outcomes for laparoscopic and open colectomy.

METHODS

Data were obtained from the National Surgical Quality Improvement Program (2005-2012) for patients undergoing colon resection [open colectomy (OC) and laparoscopic colectomy (LC)]. Patients were classified as non-frail (0 points), low frailty (1 point), moderate frailty (2 points), and severe frailty (≥ 3) using the Modified Frailty Index. 30-d mortality and complications were used as the primary end point and analyzed for the overall population. Complications were grouped into major and minor. Subset analysis was performed for patients undergoing colectomy (total colectomy, partial colectomy and sigmoid colectomy) and separately for patients undergoing rectal surgery (abdominoperineal resection, low anterior resection, and proctocolectomy). We analyzed the data using SAS Platform JMP Pro version 10.0.0 (SAS Institute Inc., Cary, NC, United States).

RESULTS

A total of 94811 patients were identified; the majority underwent OC (58.7%), were white (76.9%), and non-frail (44.8%). The median age was 61.3 years. Prolonged length of stay (LOS) occurred in 4.7%, and 30-d mortality was 2.28%. Patients undergoing OC were older (61.89 ± 15.31 vs 60.55 ± 14.93) and had a higher ASA score (48.3% ASA3 vs 57.7% ASA2 in the LC group) (P < 0.0001). Most patients were non-frail (42.5% OC vs 48% LC, P < 0.0001). Complications, prolonged LOS, and mortality were significantly more common in patients undergoing OC (P < 0.0001). OC had a higher risk of death and complications compared to LC for all frailty scores (non-frail: OR = 4.7, and OR = 4.67; mildly frail: OR = 2.51, and OR = 2.47; moderately frail: OR = 2.94, and OR = 2.02, severely frail: OR = 2.37, and OR = 2.34, P < 0.05) and an increase in absolute mortality with increasing frailty (non-frail 0.68% OC, mildly frail 1.39%, moderately frail 3.44%, and severely frail 5.83%, P < 0.0001).

CONCLUSION

LC is associated with improved outcomes. Although the odds of mortality are higher in non-frail, there is a progressive increase in mortality with increasing frailty.

Smoking Is Associated with an Increased Risk for Surgery in Diverticulitis: A Case Control Study

Importance

Cigarette smoking increases the risk of surgery in Crohn’s disease. However, the effect of smoking on the need for surgery for diverticulitis is unknown.

Objective

We evaluated whether smoking was a risk factor for surgery among patients admitted to hospital with acute diverticulitis.

Design

We conducted a population-based comparative cohort study of patients admitted to hospital for diverticulitis who were treated with medical versus surgical management.

Setting & Participants

We used the population-based Discharge Abstract Database to identify 176 adults admitted emergently with a diagnosis of diverticulitis between 2009 and 2010 in Calgary.

Intervention & Main Outcome

We performed a medical chart review to confirm the diagnosis of diverticulitis and to extract clinical data. The primary outcome was a partial colectomy during hospitalization. Logistic regression evaluated the association between smoking and surgery after adjusting for potential confounders, including age, sex, comorbidity, and disease severity.

Results

A partial colectomy was performed on 35.6% of patients with diverticulitis and 1.3% died. Among diverticulitis patients, 26.8% were current smokers, 31.5% were ex-smokers, and 41.6% never smoked. Compared to non-smokers, current smokers (adjusted odds ratio [OR] 9.02; 95% confidence interval [CI]: 2.47–32.97) and former smokers (adjusted OR 5.41; 95% CI: 1.54–18.96) had increased odds of surgery.

Conclusion and Relevance

Smoking is associated with the need for surgical management of diverticulitis.

Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization

Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database

AIM

Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States.

METHOD

The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status.

RESULTS

Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss.

CONCLUSION

Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts.

Laparoscopic versus open elective repair of primary umbilical hernias: short-term outcomes from the American College of Surgeons National Surgery Quality Improvement Program

BACKGROUND

Approximately 175,000 umbilical hernia repairs are performed annually in the US. Controversy exists regarding the optimal approach for the elective repair of primary umbilical hernias.

OBJECTIVE

The objective of this study was to compare 30-day outcomes of elective primary open (OHR) and laparoscopic (LHR) umbilical hernia repairs, using a prospectively collected dataset.

METHODS

We performed a retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program Participant Use Files during 2009 and 2010. Current Procedural Terminology and post-operative International Classification of Diseases, Ninth Revision diagnostic codes were used to identify primary umbilical hernia repairs. Primary outcomes included composite endpoints of 30-day mortality, and major and overall complications. Univariate analyses and multivariate logistic regression were performed controlling for relevant patient characteristics. Secondary outcomes included operative time and hospital length of stay (LOS).

RESULTS

Overall, 14,652 patients were identified-13,109 (89.5 %) OHR and 1543 (10.5 %) LHR. Univariate analyses of primary outcomes demonstrated similar 30-day morbidity and mortality between groups. In our multivariate model, however, after controlling for body mass index, gender, American Society of Anesthesiologists class, and chronic obstructive pulmonary disease, the odds ratio (OR) for overall complications favored LHR (OR 0.60; p = 0.01). This difference was driven primarily by the reduced wound complication rate in the LHR group [OR 0.41 (0.20, 0.78); p = 0.005]. LHR was associated with significantly longer operative time [57.7 min (SD 32.6) vs. 38.3 min (SD 22.9); p < 0.001], longer LOS [0.29 days (SD 0.68) vs. 0.17 days (SD 1.47); p = 0.001], and an increased rate of respiratory (0.52 vs. 0.10 %; p < 0.001) and cardiac (0.26 vs. 0.05 %; p = 0.005) complications.

CONCLUSIONS

This study identified potential decreased total and wound morbidity associated with LHR for elective primary umbilical hernia repairs at the expense of increased operative time, LOS, and respiratory and cardiac complications. These results should be considered within the context of a retrospective study with its inherent risks of bias and limitations.

Surgical management of complicated diverticulitis: a comparison of the laparoscopic and open approaches

BACKGROUND

Laparoscopy has become a commonly used method of performing colectomies, but the outcomes associated with laparoscopy in the emergency setting have not been well studied.

STUDY DESIGN

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients with diverticulitis without hemorrhage who underwent a colectomy. Patient data retrieved included demographics and preoperative comorbidities. Each member of the cohort received either a primary anastomosis (PA) or a colostomy. Open and laparoscopic procedures were compared within these subgroups. Multivariate logistic regression analyses were performed to compare the risk-adjusted odds of postoperative morbidity and mortality for laparoscopic and open procedures. The risk-adjusted impact of preoperative comorbidities was also assessed.

RESULTS

A total of 11,981 patients in the database met the study criteria. The majority were female (53%) and Caucasian (82%), and the mean age was 58 (±13) years. Comorbidities of the cardiovascular, pulmonary, or renal systems were present in 47%, 5%, and 1% of the cohort, respectively. On bivariate analysis, patients undergoing laparoscopy experienced lower rates of complications with both PA (14% vs 26%, p < 0.001) and colostomy (30% vs 37%, p = 0.02). The laparoscopic approach was associated with decreased mortality rates for patients undergoing PA (0.24% vs 0.79%, p < 0.001). Multivariate analysis revealed that preoperative cardiovascular and pulmonary comorbidities were each associated with increased postoperative morbidity, and that the laparoscopic approach was associated with lower postoperative morbidity for patients undergoing PA. The reduced risk of death for patients undergoing laparoscopic PA (vs open approach) did not achieve statistical significance (odds ratio 0.68, p = 0.3). A small number of patients underwent laparoscopic colostomy (n = 237, 2.4%), and they did not have a significantly different risk of death.

CONCLUSIONS

The laparoscopic approach is associated with lower complication rates compared with the open approach for the surgical treatment of diverticulitis with a primary anastomosis.

Distance bias and surgical outcomes

BACKGROUND

A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed "distance bias." This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution.

METHODS

We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient.

RESULTS

The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2-5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63-0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00-1.42)]. Operations performed on patients from greater distances (quintiles 3-5) had an observed risk of severe complications which was similar to expected.

DISCUSSION

The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.

Postoperative complications and implications on patient-centered outcomes

BACKGROUND

Postoperative complications increase patient morbidity and mortality and are a target for quality improvement programs. The goal of this study was to review the world's literature on postoperative complications in general surgery patients and try to examine the effect of these complications on patient-centered outcomes.

METHODS

A comprehensive search of the current literature identified 18 studies on the topic of postoperative complications in general surgery patients.

RESULTS

Postoperative complications are common in general surgery patients and contribute to increased mortality, length of stay, and need for an increased level of care at discharge (decline in disposition).

CONCLUSIONS

Although the concept of patient-centered outcomes is not new, it has not been applied to postoperative complications. It is likely that the effect of complications on length of hospital stay and postoperative discharge reflects an impact of complications on these patient-centered outcomes. Future studies should consider the effect of complications on those outcomes that are most important to the individual patient.