Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

Total Gastrectomy for Gastric Malignancy: Trends Over 15 Years in Major Morbidity, Mortality, and Patient Selection From The National Surgical Quality Improvement Program

INTRODUCTION

We examined trends in major morbidity and mortality following total gastrectomy for malignancy in a national cohort.

METHODS

The National Surgical Quality Improvement Program was used to identify patients who underwent total gastrectomy for malignancy from 2007 to 2021. Joinpoint regression was used to determine annual percent changes (APCs) in thirty-day postoperative major morbidity, mortality, and length of stay (LOS). Major morbidity included deep and organ space surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure.

RESULTS

Of 3515 patients, the median age was 65 years (IQR = 55-73), 59% were male, and 57.9% were White. Major morbidity was 23%, which did not change over time (APC = -1.4, 95% CI = -3.4 to 0.58), nor were there changes in individual morbidities with time. The most common morbidities were organ space surgical site infection (9.2%) and pneumonia (8.5%). Mortality rate in the study cohort was 2.7% and did not change (APC = -6.2, 95% CI = -13.0 to 1.1). LOS (median 9 days) also did not vary with time (APC = -2.3, 95% CI = -7.8 to 3.9). There was an increase in patients with diabetes (21.6% vs. 11.2%, p < 0.05), BMI ≥ 30 (31.1% vs. 18.2%, p < 0.05), and ASA IV-V status (11.6% vs. 3.5%, p < 0.05).

CONCLUSION

Morbidity and mortality following total gastrectomy for malignancy have not significantly changed over the last fifteen years. While this may in part be explained by increased patient comorbidity, efforts should be made to improve patient selection and mitigate postoperative complications to allow for timely adjuvant therapies.

Laparoscopic training workshop to assess medical students' skill acquisition and interest in surgical careers

BACKGROUND

With its minimally invasive approach, laparoscopic surgery has transformed the medical landscape. As the demand for these procedures escalates, there is a pressing need for adept surgeons trained in laparoscopic techniques. However, current training often falls short of catering to medical school education. This study evaluates the impact of a custom-designed laparoscopic training workshop on medical students' surgical skills and career aspirations.

METHODS

This prospective experimental study was conducted at the E-Da hospital in Kaohsiung City, Taiwan. Medical students from Taiwanese medical schools undergoing Clerk 5, Clerk 6, and Postgraduate Year 1 and 2 were invited to participate. Medical students (n = 44) underwent an endoscopic skill training workshop consisting of lectures, box training, and live tissue training. The trainees performed multiple tasks before and after training using our objective evaluation system. The primary outcome was assessed before and after training through a questionnaire assessing the influence of training on students' interest in surgery as a career. The secondary outcome measured improvement in skill acquisition, comparing the task completion time pre- and post-workshop. For the primary outcome, descriptive statistics were used to summarize the questionnaire responses, and paired t-tests were performed to determine significant changes in interest levels post-workshop. For the secondary outcome, paired t-tests were used to compare the time recorded pre- and post-training.

RESULTS

Post-training, participants exhibited significant proficiency gains, with task completion times reducing notably: 97 s (p = 0.0015) for Precision Beads Placement, 88.5 s (p < 0.0001) for Beads Transfer Exercise, 95 s (p < 0.0001) for Precision Balloon Cutting, and 137.8 s (p < 0.0001) for Intracorporeal Suture. The primary outcome showcased an increased mean score from 8.15 pre-workshop to 9.3 post-workshop, indicating a bolstered interest in surgery as a career. Additionally, post-training sentiment analysis underscored a predominant inclination toward surgery among 88% of participants.

CONCLUSION

The custom-designed laparoscopic workshop significantly improved technical skills and positively influenced students' career aspirations toward surgery. Such hands-on training workshops can play a crucial role in medical education, bridging the gap between theoretical knowledge and practical skills and potentially shaping the future of budding medical professionals.

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Resection margins, lymph node harvest and 3 year survival in open and laparoscopic colorectal cancer surgery; a prospective cohort study

INTRODUCTION

Laparoscopic colorectal cancer surgery has been gaining popularity in the last decade. However, there are concerns about adequate lymph node dissection and safe resection margins in laparoscopic colorectal cancer surgery. This study was aimed at comparing the lymph node (LN) clearance and surgical resection margins and 3-year survival for open and laparoscopic colorectal cancer surgery.

METHOD

A pre-tested interviewer administered questionnaire was used to assess the adoption of the laparoscopic approach by Sri Lankan surgeons. Data was collected prospectively from patients who underwent open or laparoscopic colorectal cancer surgery at the University Surgical Unit of the National Hospital of Sri Lanka from April 2016 to May 2019. The histopathology records were analysed to determine the longitudinal and circumferential resection margins(CRM) and the number of lymph nodes harvested. The resection margins were classified as positive or negative. The total number of LN examined was evaluated. Presence of local recurrence and liver metastasis was determined by contrast enhanced CT scan during 3-years of follow up. Chi square, T test and z test for proportions were used to compare CRM, LN harvest and survival rates between the groups.

RESULTS

Of the surgeons interviewed only 11 (18.4%) performed laparoscopic colorectal cancer surgery. A total of 137 patients (83 males and 54 females) were studied. Eighty-one procedures were laparoscopic and 56 procedures were open. All patients had clear longitudinal resection margins. Seventy-eight patients in the laparoscopic group (96%) and 51 patients (91%) in the open group had clear CRM (p > 0.05). A total of 2188 LNs (mean 15.9) were resected in all procedures. Six-hundred-eighty-nine lymph nodes were removed during open procedures (mean 12.3, SD 0.4) and 1499 (mean 18.5, SD 0.6) were removed during laparoscopy (p < 0.05). At 3 years follow-up the disease-free survival in the laparoscopic and open colon cancer patients was 27/41 (65.8%) and 16/29 (55.1%) respectively (p = 0.35). Disease free survival in the laparoscopic and open rectal cancer patients was 23/38 (60.5%) and 13/25 (52.0%) respectively (p = 0.40). Four patients were lost during follow-up.

DISCUSSION AND CONCLUSION

CRM was comparable in the two groups. Laparoscopic group had a significantly higher LN harvest. Three-year survival rates were similar in the two groups. Acceptable results can be obtained with laparoscopic colorectal cancer surgery.

Disparities in access to minimally invasive surgery for inflammatory bowel disease and outcomes by insurance status: analysis of the 2015 to 2019 National Inpatient Sample

INTRODUCTION

Despite being the preferred modality for treatment of colorectal cancer and diverticular disease, minimally invasive surgery (MIS) has been adopted slowly for treatment of inflammatory bowel disease (IBD) due to its technical challenges. The present study aims to assess the disparities in use of MIS for patients with IBD.

METHODS

A retrospective analysis of the National Inpatient Sample (NIS) database from October 2015 to December 2019 was conducted. Patients < 65 years of age were stratified by either private insurance or Medicaid. The primary outcome was access to MIS and secondary outcomes were in-hospital mortality, complications, length of stay (LOS), and total admission cost. Univariate and multivariate regression was utilized to determine the association between insurance status and outcomes.

RESULTS

The NIS sample population included 7866 patients with private insurance and 1689 with Medicaid. Medicaid patients had lower odds of receiving MIS than private insurance patients (OR 0.85, 95% CI [0.74-0.97], p = 0.017), and experienced more postoperative genitourinary complications (OR 1.36, 95% CI [1.08-1.71], p = 0.009). In addition, LOS was longer by 1.76 days (p < 0.001) and the total cost was higher by $5043 USD (p < 0.001) in the Medicaid group. Independent predictors of receiving MIS were age < 40 years old, female sex, highest income quartile, diagnosis of ulcerative colitis, elective admission, and care at teaching hospitals.

CONCLUSIONS

Patients with Medicaid are less likely to receive MIS, have longer lengths of stay, and incur higher costs for the surgical management of their IBD. Further investigations into disparities in inflammatory bowel disease care for Medicaid patients are warranted.

Impact of imaging magnification on colorectal surgery: a matched analysis of a single tertiary center

BACKGROUND

Laparoscopy has been increasingly applied in colorectal surgery, and imaging systems have been improving concurrently. The present study aims to compare outcomes following colorectal surgery with the 4K and traditional high-definition (HD) video systems.

METHODS

All consecutive patients undergoing laparoscopic colorectal surgery between April 2016 and June 2020 were retrospectively retrieved from a prospective institutional database. The study population was matched according to the imaging system (4K versus HD groups) through a propensity score matching (PSM) based on perioperative characteristics of 15 patients. A stratified analysis according to surgical procedures (right, left colectomy, and low anterior resection) was also performed. Primary endpoints were intraoperative blood loss and perioperative transfusions. Also, intra- and postoperative morbidity, operative time, lymph node harvest, and length of hospital stay (LOS) were investigated as secondary outcomes.

RESULTS

After PSM, 225 patients were included in both 4K and HD groups. The intraoperative blood loss was significantly lower in the 4K group (p = 0.008), although no different volumes of blood transfusion were required. Postoperative complications presented in similar proportions, while significantly higher rates of abdominal collection (p = 0.045), reoperation (p = 0.005), and postoperative urinary disorders occurred in the HD group. After stratification, the right colectomy subgroup shared similar associations with the study population. LOS did not change between groups, although readmissions were significantly lower in the 4K group (p < 0.001).

CONCLUSIONS

The 4K imaging system represents a technological advance providing better surgical outcomes, such as the minimization of intraoperative blood loss and postoperative morbidity.

Is non-mentored initiation of laparoscopic colorectal surgery safe? Single surgeon initial experience with the first 40 cases

Introduction

Although laparoscopic colorectal surgery is now accepted as a standard procedure in treating colorectal cancer, the proportion of laparoscopically operated patients with colorectal cancer is still generally quite low. The aim of this study is to assess feasibility, safety, and outcomes of a non-mentored initiation of laparoscopic colorectal resections by a young surgeon without previous experience in laparoscopic colorectal surgery.

Materials and methods

We analyzed the characteristics of the first 40 elective cases of laparoscopic colorectal resections performed by a single surgeon during the period between June 2019 and March 2022. All of the operations were performed without the attendance or supervision of an experienced surgeon in laparoscopic colorectal surgery. The patients were divided into three groups (the early, intermediate, and late group).

Results

The conversion rate, complications rate, and postoperative recovery were similar among groups. The mean overall operative time was 219.5 min (range 130-420 min) and had reduced significantly during the learning curve (p = 0.047). The overall conversion rate was 12.5%. In two cases (5%), the oncological principles were violated (incomplete total mesorectal excision). In three patients (7.5%), intraoperative complications had occurred (small bowel injury, splenic injury, and significant bleeding from the minor peripancreatic artery). Three cases of major postoperative complications (Clavien-Dindo grade III) were recorded, two of which required reoperation (anastomotic bleeding and fascial dehiscence). There was no 90-day mortality reported. The overall mean number of lymph nodes retrieved was 12.45, which did not differ significantly among groups (p = 0.678). The average follow-up was 13.75 months (range 1-31 months). Cancer recurrence was recorded in four patients (10%). Port-site metastasis was not detected in any of the cases.

Conclusion

A safe and non-mentored initiation of laparoscopic colorectal surgery with an acceptable rate of complications and acceptable oncological results can be achieved. Still, when compared with a structured initiation in a controlled environment with the supervision of an experienced surgeon in laparoscopic colorectal surgery, the results of a non-mentored initiation are worse in most of the fields, including operative time, conversion rate, complications rate, and duration of hospital stay. Therefore, I strongly recommend engaging young surgeons in fellowship programs on structured laparoscopic colorectal surgery whenever possible before starting performing these procedures on their own.

Medicare Reimbursement in Colorectal Surgery: A Growing Problem

BACKGROUND

Medicare reimbursement rates have decreased across various specialties but have not yet been studied in colorectal surgery.

OBJECTIVE

This study aimed to analyze Medicare reimbursement trends in colorectal surgery.

DESIGN

Observational study.

SETTING

The Centers for Medicare and Medicaid Services' Physician Fee Schedule was evaluated for reimbursement data for the 20 most common colorectal surgery procedures from 2006 to 2020.

MAIN OUTCOME MEASURES

Inflation-adjusted annual percentage change, compound annual growth rate, and total percentage change were the outcome measures. A subanalysis was performed comparing the changes in reimbursement between 2006 to 2016 and 2016 to 2020 because of legislative changes that went into effect in 2016.

RESULTS

During the study period, the inflation-unadjusted mean Medicare reimbursement rate for the 20 most common colorectal surgery procedures increased by +15.6%. This rise was surpassed by the inflation rate of +31.3%. Consequently, the inflation-adjusted reimbursement rate decreased by -11%. The adjusted reimbursement rates decreased the most at -33.8% for a flexible colonoscopy with biopsy and increased the most at +45.3% for a diagnostic rigid proctosigmoidoscopy. Annual percentage change was -0.79%, and the compound annual growth rate was -0.98%. There was an accelerated decrease in annual reimbursement rates from 2016 to 2020 at -2.23% compared to 2006 to 2016 at -0.22% ( p = 0.03). The only procedure that had an increase in adjusted reimbursement rate from 2016 to 2020 was the injection of sclerosing solution for hemorrhoids.

LIMITATIONS

Only Medicare reimbursement data were analyzed.

CONCLUSIONS

Medicare reimbursements for colorectal surgery procedures are decreasing at an accelerating rate. Although this study is limited to Medicare data, it still presents a representation of overall reimbursement changes because Medicare policies have a ripple effect in the commercial insurance market. It is vital to understand the financial trends to be able to structure future patient care teams and to advocate for the sustainability of colorectal surgery practices in the United States. See Video Abstract at http://links.lww.com/DCR/C136 .

REEMBOLSO DE MEDICARE EN CIRUGA COLORRECTAL UN PROBLEMA CRECIENTE

ANTECEDENTES: Las tasas de reembolso de Medicare han disminuido en varias especialidades, pero aún no han sido estudiado en cirugía colorrectal.OBJETIVO: Analizar las tendencias de reembolso de Medicare en cirugía colorrectal.DISEÑO: Estudio observacional.CONTEXTO: Se evaluó el programa de tarifas médicas de los Centros de Servicios de Medicare y Medicaid para obtener datos de reembolso de los 20 procedimientos más comunes en cirugía colorrectal entre los años 2006 y 2020.PRINCIPALES MEDIDAS DE RESULTADO: Variación porcentual anual ajustada por inflación, tasa de crecimiento anual compuesta y variación porcentual total. Se realizó un subanálisis comparando los cambios en el reembolso entre los años 2006 a 2016 y 2016 a 2020 debido a los cambios legislativos que entraron en vigencia en 2016.RESULTADOS: Durante el período de estudio, la tasa media de reembolso de Medicare sin ajuste por inflación para los 20 procedimientos más comunes en cirugía colorrectal aumentó en +15,6 %. Esta suba fue superada por la tasa de inflación del +31,3%. En consecuencia, la tasa de reembolso ajustada por inflación disminuyó un -11%. Lo máximo que disminuyeron las tasas ajustadas de reembolso fue a -33,8% para una colonoscopia flexible con biopsia y aumentaron más a +45,3% para una proctosigmoidoscopia rígida de diagnóstico. El cambio porcentual anual fue -0,79% y la tasa de crecimiento anual compuesto fue -0,98%. Hubo una disminución acelerada en las tasas de reembolso anual de 2016 a 2020 a -2,23 % en comparación con 2006 a 2016 a -0,22% ( p = 0,03). El único procedimiento que tuvo un aumento en la tasa de reembolso ajustada de 2016 a 2020 fue la inyección de solución esclerosante para las hemorroides.LIMITACIONES: Solo se analizaron los datos de reembolso de Medicare.CONCLUSIONES: Los reembolsos de Medicare por procedimientos en cirugía colorrectal están disminuyendo a un ritmo acelerado. Aunque este estudio se limita a los datos de Medicare, aún presenta una representación de los cambios generales en los reembolsos, ya que las pólizas de Medicare tienen un efecto dominó en el mercado de seguros comerciales. Es fundamental comprender las tendencias financieras para poder estructurar futuros equipos de atención de pacientes y abogar por la sostenibilidad de las prácticas de cirugía colorrectal en los Estados Unidos. Consulte Video Resumen video en https://links.lww.com/DCR/C136 . (Traducción-Dr. Osvaldo Gauto ).

Relationship between body mass index and short-term postoperative prognosis in patients undergoing colorectal cancer surgery

BACKGROUND

Obesity is a state in which excess heat is converted into excess fat, which accumulates in the body and may cause damage to multiple organs of the circulatory, endocrine, and digestive systems. Studies have shown that the accumulation of abdominal fat and mesenteric fat hypertrophy in patients with obesity makes laparoscopic surgery highly difficult, which is not conducive to operation and affects patient prognosis. However, there is still controversy regarding these conclusions.

AIM

To explore the relationship between body mass index (BMI) and short-term prognosis after surgery for colorectal cancer.

METHODS

PubMed, Embase, Ovid, Web of Science, CNKI, and China Biology Medicine Disc databases were searched to obtain relevant articles on this topic. After the articles were screened according to the inclusion and exclusion criteria and the risk of literature bias was assessed using the Newcastle-Ottawa Scale, the prognostic indicators were combined and analyzed.

RESULTS

A total of 16 articles were included for quantitative analysis, and 15588 patients undergoing colorectal cancer surgery were included in the study, including 3775 patients with obesity and 11813 patients without obesity. Among them, 12 articles used BMI ≥ 30 kg/m² and 4 articles used BMI ≥ 25 kg/m² for the definition of obesity. Four patients underwent robotic colorectal surgery, whereas 12 underwent conventional laparoscopic colorectal resection. The quality of the literature was good. Meta-combined analysis showed that the overall complication rate of patients with obesity after surgery was higher than that of patients without obesity [OR = 1.35, 95%CI: 1.23-1.48, Z = 6.25, P < 0.0001]. The incidence of anastomotic leak after surgery in patients with obesity was not significantly different from that in patients without obesity [OR = 0.99, 95%CI: 0.70-1.41), Z = -0.06, P = 0.956]. The incidence of surgical site infection (SSI) after surgery in patients with obesity was higher than that in patients without obesity [OR = 1.43, 95%CI: 1.16-1.78, Z = 3.31, P < 0.001]. The incidence of reoperation in patients with obesity after surgery was higher than that in patients without obesity; however, the difference was not statistically significant [OR = 1.15, 95%CI: 0.92-1.45, Z = 1.23, P = 0.23]; Patients with obesity had lower mortality after surgery than patients without obesity; however, the difference was not statistically significant [OR = 0.61, 95%CI: 0.35-1.06, Z = -1.75, P = 0.08]. Subgroup analysis revealed that the geographical location of the institute was one of the sources of heterogeneity. Robot-assisted surgery was not significantly different from traditional laparoscopic resection in terms of the incidence of complications.

CONCLUSION

Obesity increases the overall complication and SSI rates of patients undergoing colorectal cancer surgery but has no influence on the incidence of anastomotic leak, reoperation rate, and short-term mortality rate.

Quality of life and function after rectal cancer surgery with and without sphincter preservation

Despite improvements in surgical techniques, functional outcomes and quality of life after therapy for rectal cancer remain suboptimal. We sought to prospectively evaluate the effect of bowel, bladder, and sexual functional outcomes on health-related quality of life (QOL) in patients with restorative versus non-restorative resections after rectal cancer surgery. A cohort of 211 patients with clinical stage I-III rectal cancer who underwent open surgery between 2006 and 2009 at Memorial Sloan Kettering were included. Subjects were asked to complete surveys preoperatively and at 6, 12, and 24 months after surgery. Validated instruments were used to measure QOL, bowel, bladder, and sexual function. Univariable and multivariable regression analyses evaluated predictors of 24- month QOL. In addition, longitudinal trends over the study period were evaluated using repeated measures models. In total, 180 patients (85%) completed at least 1 survey, and response rates at each time point were high (>70%). QOL was most impaired at 6 and 12 months and returned to baseline levels at 24 months. Among patients who underwent sphincter-preserving surgery (SPS; n=153 [85%]), overall bowel function at 24 months was significantly impaired and never returned to baseline. There were no differences in QOL at 24 months between patients who underwent SPS and those who did not (p=.29). Bowel function was correlated with QOL at 24 months (Pearson correlation,.41; p<.001). QOL among patients who have undergone SPS for rectal cancer is good despite poor function. Patients with ostomies are able to adjust to the functional changes and, overall, have good global QOL. Patients with low anastomoses had lower global QOL at 24 months than patients with permanent stomas. Our findings can help patients set expectations about function and quality of life after surgery for rectal cancer with and without a permanent stoma.

Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic

Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien–Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.

Can you trust clinical practice guidelines for laparoscopic surgery? A systematic review of clinical practice guidelines for laparoscopic surgery

BACKGROUND

Clinical practice guidelines aim to support clinicians in providing clinical care and should be supported by evidence. There is currently no information on whether clinical practice guidelines in laparoscopic surgery are supported by evidence.

METHODS

We performed a systematic review and identified clinical practice guidelines of laparoscopic surgery published in PubMed and Embase between March 2016 and February 2019. We performed an independent assessment of the strength of recommendation based on the evidence provided by the guideline authors. We used the 'Appraisal of Guidelines for Research & Evaluation II' (AGREE-II) Tool's 'rigour of development', 'clarity of presentation', and 'editorial independence' domains to assess the quality of the guidelines. We performed a mixed-effects generalised linear regression modelling.

RESULTS

We retrieved 63 guidelines containing 1905 guideline statements. The median proportion of 'difference in rating' of strength of recommendation between the guideline authors and independent assessment was 33.3% (quartiles: 18.3%, 55.8%). The 'rigour of development' domain score (odds ratio 0.06; 95% confidence intervals 0.01-0.48 per unit increase in rigour score; P value = 0.0071) and whether the strength of recommendation was 'strong' by independent evaluation (odds ratio 0.09 (95% confidence intervals 0.06-0.13; P value < 0.001) were the only determinants of difference in rating between the guideline authors and independent evaluation.

CONCLUSION

A considerable proportion of guideline statements in clinical practice guidelines in laparoscopic surgery are not supported by evidence. Guideline authors systematically overrated the strength of the recommendation (i.e., even when the evidence points to weak recommendation, guideline authors made strong recommendations).

Evaluation of Advanced Bimanual Skills in Novices Using the Wrist-Like FlexDex™ Articulating Laparoscopic Needle Holder in 2D and 3D Vision: A Randomised Trial

Aim

The aim of this study was to evaluate the novice performance of advanced bimanual laparoscopic skills using the articulating FlexDex^TM laparoscopic needle holder in two-dimensional (2D) and three-dimensional (3D) visual systems.

Methods

In this prospective randomised trial, novices (n=40) without laparoscopic experience were recruited from a university cohort and randomised into two groups, which used the FlexDex^TM and 2D or the FlexDex™ and 3D. Both groups performed 10 repetitions of a validated assessment task. Times taken and error rates were measured, and assessments were made based on completion times, error rates and learning curves.

Results

The intervention group that used FlexDex^TM and 3D visual output completed 10 attempts of the standardised laparoscopic task quicker than the control group that used FlexDex^TM with standard 2D visual output (268 seconds vs 415 seconds taken for the first three attempts and 176 seconds vs 283 seconds taken for the last three attempts, respectively). Moreover, each attempt was completed faster by the intervention group compared to the control group. The difference in average time for the first three and last three attempts reached statistical significance (P < 0.001).

Conclusion

Combination of 3D visual systems and the FlexDex^TM laparoscopic needle holder resulted in superior task performance speed, leading to shorter completion times and quicker learning effect. Although the 3D group demonstrated lower mean error rates, it did not reach statistical significance.

Key Statement

3D visual systems lead to faster task completion times when combined with an articulating laparoscopic needle holder compared to 2D vision. This effect however is not seen in error rates.

Impact of Medicaid Expansion on the Diagnosis, Treatment, and Outcomes of Stage II and III Rectal Cancer Patients

BACKGROUND

Insurance status has been associated with disparities in stage at cancer diagnosis. We examined how Medicaid expansion (ME) impacted diagnoses, surgical treatment, use of neoadjuvant therapies (NCRT), and outcomes for Stage II and III rectal cancer.

STUDY DESIGN

We used 2010-2017 American College of Surgeons National Cancer Database (NCDB) to identify patients ages 18-65, with Medicaid as primary form of payment, and were diagnosed with Stage II or III rectal cancer. Patients were stratified based on Census bureau division's ME adoption rates of High, Medium, Low. Overall trends were examined, and patient characteristics and outcomes were compared before and after ME date of 1/1/2014.

RESULTS

Over 8 years of NCDB data examined, there was an increasing trend of Stage II and III rectal cancer diagnoses, surgical resection, and use of NCRT for Medicaid patients. We observed an increase in age, proportion of White Medicaid patients in Low ME divisions, and proportion of fourth income quartile patients in High ME divisions. Univariate analysis showed decreased use of open surgery for all 3 categories after ME, but adjusted odds ratios (aOR) were not significant based on multivariate analysis. NCRT utilization increased after ME for all 3 ME adoption categories and aOR significantly increased for Low and High ME divisions. ME significantly decreased 90-day mortality.

CONCLUSIONS

Medicaid expansion had important impacts on increasing Stage II and III rectal cancer diagnoses, use of NCRT, and decreased 90-day mortality for patients with Medicaid. Our study supports increasing health insurance coverage to improve Medicaid patient outcomes in rectal cancer care.

Minimally Invasive Surgery is Associated with Improved Outcomes Following Urgent Inpatient Colectomy

Objectives

The use of minimally invasive techniques for urgent colectomies remains understudied. This study compares short-term outcomes following urgent minimally invasive colectomies to those following open colectomies.

Methods & Procedures

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) colectomy database was queried between January 1, 2013 and December 31, 2018. Patients who underwent elective and emergency colectomies, based on the respective NSQIP variables, were excluded. The remaining patients were divided into two groups, minimally invasive surgery (MIS) and open. MIS colectomies with unplanned conversion to open were included in the MIS group. Baseline characteristics and 30-day outcomes were compared using univariable and multivariable regression analyses.

Results

A total of 29,345 patients were included in the study; 12,721 (43.3%) underwent MIS colectomy, while 16,624 (56.7%) underwent open colectomy. Patients undergoing MIS colectomy were younger (60.6 vs 63.8 years) and had a lower prevalence of either American Society of Anesthesiology (ASA) IV (9.9 vs 15.5%) or ASA V (0.08% vs 2%). After multivariable analysis, MIS colectomy was associated with lower odds of mortality (odds ratio = 0.75, 95% confidence interval: 0.61, 0.91 95% confidence interval), and most short-term complications recorded in the ACS NSQIP. While MIS colectomies took longer to perform (161 vs 140 min), the length of stay was shorter (12.2 vs 14.1 days).

Conclusions

MIS colectomy affords better short-term complication rates and a reduced length of stay compared to open colectomy for patients requiring urgent surgery. If feasible, minimally invasive colectomy should be offered to patients necessitating urgent colon resection.

Urgent Inpatient Colectomy Carries a Higher Morbidity and Mortality than Elective Surgery

BACKGROUND

Emergency colorectal surgery confers a higher risk of adverse outcomes compared to elective surgery. Few studies have examined the outcomes after urgent colectomies, typically defined as those performed at the index admission, but not performed at admission in an emergency fashion. The aim of this study is to evaluate the risk of adverse outcomes following urgent inpatient colorectal surgery.

MATERIALS AND METHODS

All adult patients undergoing colectomy between 2013 and 2017 in the ACS NSQIP were included in the analysis. Patients were grouped into Elective, Urgent and Emergency groups. The Urgent group was further stratified by time from admission to surgery. Baseline characteristics and 30 day outcomes were compared between the Elective, Urgent and Emergency groups using univariable and multivariable analyses.

RESULTS

104,486 patients underwent elective colorectal resection. 23,179 underwent urgent while 22,241 had emergency resections. Patients undergoing urgent colectomy presented with increased comorbidities, and experienced higher mortality (2.5-4.1%, AOR 2.3 (1.9 - 2.8)) compared to elective surgery (0.4%). Urgent colectomy was an independent risk factor for the majority of short term complications documented in NSQIP. Moreover, patients undergoing urgent colectomy more than a week following admission had an increased risk of bleeding, deep venous thrombosis, pulmonary embolism, urinary tract infection, and prolonged hospitalization.

CONCLUSION

Urgent colectomies are associated with a greater risk of adverse outcomes compared to elective surgery. Urgent status is an independent risk factor for post operative mortality and morbidity. Further characterization of this patient population and their specific challenges may help ameliorate these adverse events.

Trends in Open, Laparoscopic, and Robotic Approaches to Colorectal Operations

The use of robotic approach has gained momentum in colorectal surgery. We analyzed the trends in the adoption of robotic-assisted platform (RAP) for colorectal surgery over a 6-year period (2013-2018) using the American College of Surgeons National Surgical Quality Improvement Project. We assessed yearly prevalence of robotic, laparoscopic, and open approaches, and evaluated trends in the adoption of RAP across age, gender, BMI, and American Society of Anesthesiology (ASA) subgroups. Overall, the frequency of open, laparoscopic, and robotic approach was 36%, 46.8%, and 7.8%, respectively. While the use of laparoscopic cases remained stable over the study period, the prevalence of RAP increased from 2.8% to 11.4%. This was accompanied by a concomitant decline in the use of open approach, from 40.8% to 33%. The use of RAP also increased across all age, gender, BMI, and ASA subgroups. Robotic-assisted platform is increasingly utilized for higher risk, older, and obese patients, allowing more patients to receive minimally invasive colorectal surgery.

Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection

PURPOSE

The Enhanced Recovery After Surgery (ERAS) protocol reduces complications and length of stay (LOS) in colon cancer, but implementation in rectal cancer is different because of neo-adjuvant therapy and surgical differences. Laparoscopic resection may further improve outcome. The aim of this study was to evaluate the effects of introducing ERAS on postoperative outcome after rectal cancer resection in an era of increasing laparoscopic resections.

MATERIALS AND METHODS

Patients who underwent elective rectal cancer surgery from 2009 till 2015 were included in this observational cohort study. In 2010, ERAS was introduced and adherence to the protocol was registered. Open and laparoscopic resections were compared. With regression analysis, predictive factors for postoperative outcome and LOS were identified.

RESULTS

A total of 499 patients were included. The LOS decreased from 12.3 days in 2009 to 5.7 days in 2015 (p = 0.000). Surgical site infections were reduced from 24% in 2009 to 5% in 2015 (p = 0.013) and postoperative ileus from 39% in 2009 to 6% in 2015 (p = 0.000). Only postoperative ERAS items and laparoscopic surgery were associated with an improved postoperative outcome and shorter LOS.

CONCLUSIONS

ERAS proved to be feasible, safe, and contributed to improving short-term outcome in rectal cancer resections. The benefits of laparoscopic surgery may in part be explained by reaching better ERAS adherence rates. However, the laparoscopic approach was also associated with anastomotic leakage. Despite the potential of bias, this study provides an insight in effects of ERAS and laparoscopic surgery in a non-randomized real-time setting.

Anatomical framework for pre-operative planning of laparoscopic left-sided colorectal surgery: Potential relevance of the distance between the inferior mesenteric artery and inferior mesenteric vein

BACKGROUND

The medial-to-lateral approach is favored by most colorectal surgeons for laparoscopic retroperitoneal dissection and mobilisation of the left colon. The peritoneal access window, i.e. the distance between the inferior mesenteric vein (IMV) and inferior mesenteric artery (IMA) must be large enough to perform the procedure safely and successfully. However, studies investigating the IMA-IMV distance and factors affecting this variable, are scarce. Therefore, we examined the IMA-IMV and D3-IMA distances to determine an anatomical framework on planning and adapting surgical therapy.

BASIC PROCEDURES

The IMA-IMV and D3-IMA distances were retrospectively measured in 230 patients (127 Male/103 Female, Median Age=54.5) who had undergone pre-operative CT-scanning before laparoscopic left-sided colorectal surgery. Two observers rated the images and interrater reliability was calculated. Subgroup, simple and multiple linear regression analyses were performed in order to detect potential interaction between morphometric variables and IMA-IMV distance.

MAIN FINDINGS

We demonstrated a significant correlation between the inferior margin of the duodenum and the origin of IMA. Determination of the IMA-IMV distance was simple and reproducible. Approximately 45% of patients undergoing laparoscopic colorectal procedures had a narrow distance (≤50mm). There was a sexual dimorphism in IMA-IMV distance, being consistently large in males. There were no other pre-operative factors which predicted whether the peritoneal dissection window for a medial-to-lateral approach was sufficient.

CONCLUSIONS

Our results provide new data for a better understanding of metric variations in abdominal vascular structures and complement previous observations. In view of our results, we recommend pre-operative measurement of the IMA-IMV before colorectal surgery where the medial-to-lateral approach is planned. Given that a narrow distance may predict a difficult dissection, this factor should be taken into account to determine the optimal surgical approach in each patient.

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice

Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far.

Aim To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons.

Methods A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations.

Results 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don’t perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption.

Conclusions Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

Inequalities in access to minimally invasive general surgery: a comprehensive nationwide analysis across 20 years

Background

Minimally invasive surgery (MIS) has profoundly changed standards of care and lowered perioperative morbidity, but its temporal implementation and factors favoring MIS access remain elusive. We aimed to comprehensibly investigate MIS adoption across different surgical procedures over 20 years, identify predictors for MIS amenability and compare propensity score-matched outcomes among MIS and open surgery.

Methods

Nationwide retrospective analysis of all hospitalizations in Switzerland between 1998 and 2017. Appendectomies (n = 186,929), cholecystectomies (n = 57,788), oncological right (n = 9138) and left hemicolectomies (n = 21,580), rectal resections (n = 13,989) and gastrectomies for carcinoma (n = 6606) were included. Endpoints were assessment of temporal MIS implementation, identification of predictors for MIS access and comparison of propensity score-matched outcomes among MIS and open surgery.

Results

The rates of MIS increased for all procedures during the study period (p ≤ 0.001). While half of all appendectomies were performed laparoscopically by 2005, minimally invasive oncological colorectal resections reached 50% only by 2016. Multivariate analyses identified older age (p ≤ 0.02, except gastrectomy), higher comorbidities (p ≤ 0.001, except rectal resections), lack of private insurance (p ≤ 0.01) as well as rural residence (p ≤ 0.01) with impaired access to MIS. Rural residence correlated with low income regions (p ≤ 0.001), which themselves were associated with decreased MIS access. Geographical mapping confirmed strong disparities for rural and low-income areas in MIS access. Matched outcome analyses revealed benefits of MIS for length of stay, decreased surgical site infection rates for MIS appendectomies and cholecystectomies and higher mortality for open cholecystectomies. No consistent morbidity or mortality benefit for MIS compared to open colorectal resections was observed.

Conclusion

Unequal access to MIS exists in disfavor of older and more comorbid patients and those lacking private insurance, living in rural areas, and having lower income. Efforts should be made to ensure equal MIS access regardless of socioeconomic or geographical factors.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08123-0) contains supplementary material, which is available to authorized users.

An early introduction to surgical skills: Validating a low-cost laparoscopic skill training program purpose built for undergraduate medical education

BACKGROUND

Medical student exposure to laparoscopy is limited to observation despite the prevalence of minimally invasive techniques in practice. The high cost of laparoscopic simulation equipment, commonly called "box trainers", limits undergraduate exposure to skill training.

METHODS

Students at a Midwestern medical school were recruited to participate in an experimental laparoscopic skill training program. One cohort (n = 17) used a DIY box trainer design freely available on MedEdPORTAL. A second cohort (n = 17) used a commercially available equivalent. Pre- and post-training attempts for four tasks were scored and the difference was calculated. The average differences for each cohort were then contrasted statistically.

RESULTS

Significant performance improvements (pre- and post-training) were demonstrated regardless of group allocation. The difference in performance between the cohorts was not significant for any task (p > 0.05).

CONCLUSIONS

This low-cost training program using DIY box trainers is as effective as commercially available equivalent box trainers for introducing laparoscopic skills to medical students.

Internet-based survey of the perceptions of surgical scars of Japanese patients

Introduction:

The adverse aesthetic effects of post-surgical scars frequently impose a psychological burden on patients. We conducted an Internet-based questionnaire survey of Japanese individuals to explore patient satisfaction with respect to surgical scars and to identify the factors that affect their interest and experience of scar care.

Method:

A cross-sectional study was conducted for the previous year on patients who had undergone the following surgeries: gastrointestinal; orthopaedic; obstetric; gynaecological; and plastic. The questionnaire included: (1) measures of participant characteristics; (2) measures of interest, experience and satisfaction with scar care; (3) measures of current and desired scar condition; and (4) measures of communication with physicians or nurses.

Results:

A total of 214 participants were enrolled. Of these, only 90 individuals had experienced any treatment or self-care, and only 30 were satisfied with their experience. We found a significant gap between the current and desired thickness and colour of the scar (P < 0.01). On logistic regression analysis, scars located at a visible site and size of the scar were significant factors that affected the interest and experience of scar care. Only 40% of participants answered that their physician or nurse adequately understands their concerns pertaining to the scar condition.

Conclusion:

Only a small proportion of individuals were satisfied with their experience of scar care. Additional research in following areas is required: (1) mutual communication between patients and medical providers; and (2) development of a new care programme for the management of scars.

Scar formation at the site of surgery is a natural biological response. The cosmetic effects of scar have an adverse psychological impact on the patient owing to the visible difference between the normal skin and scar. In the present study, we explored scar satisfaction and identified the factors that affect the patient’s interest and experience with respect to scar care. An Internet-based questionnaire survey of Japanese residents was conducted. The target population included patients who underwent gastrointestinal, orthopaedic, obstetrics and gynaecological, and plastic surgery. Out of 214 participants, 90 had experienced any treatment or self-care for scar care and only 30 were satisfied with their experience. There was a gap between the current and desired condition of thickness and colour in a scar. Scars located on visible parts of the body and size of scar had the greatest impact on the patient’s interest and experience of scar care. Additional research is required in the following areas: (1) better communication between patients and medical providers; and (2) development of new care program for scar management.

Brain activation during laparoscopic tasks in high- and low-performing medical students: a pilot fMRI study

BACKGROUND

Up to 20% of medical students are unable to reach competency in laparoscopic surgery. It is unknown whether these difficulties arise from heterogeneity in neurological functioning across individuals. We sought to examine the differences in neurological functioning during laparoscopic tasks between high- and low-performing medical students using functional magnetic resonance imaging (fMRI).

METHODS

This prospective cohort study enrolled North American medical students who were within the top 20% and bottom 20% of laparoscopic performers from a previous study. Brain activation was recorded using fMRI while participants performed peg-pointing, intracorporeal knot tying (IKT), and the Pictorial Surface Orientation (PicSOr) test. Brain activation maps were created and areas of activation were compared between groups.

RESULTS

In total, 9/12 high and 9/13 low performers completed the study. High performers completed IKT faster and made more successful knot ties than low performers [standing: 23.5 (5.0) sec vs. 37.6 (18.4) sec, p = 0.03; supine: 23.2 (2.5) sec vs. 72.7 (62.8) sec, p = 0.02; number of successful ties supine, 3 ties vs. 1 tie, p = 0.01]. Low performers showed more brain activation than high performers in the peg-pointing task (q < 0.01), with no activation differences in the IKT task. There were no behavioral differences in the PiCSOr task.

CONCLUSIONS

This study is the first to show differences between low and high performers of laparoscopic tasks at the brain level. This pilot study has shown the feasibility of using fMRI to examine laparoscopic surgical skills. Future studies are needed for further exploration of our initial findings.

Updated outcomes of laparoscopic versus open umbilical hernia repair in patients with obesity based on a National Surgical Quality Improvement Program review

BACKGROUND

Currently, there's not a well-accepted optimal approach for umbilical hernia repair in patients with obesity when comparing laparoscopic umbilical hernia repair (LUHR) versus open umbilical hernia repair (OUHR).

OBJECTIVE

The objective of this study was to evaluate if there's a difference in postoperative complications after LUHR versus OUHR with the goal of indicating an optimal approach.

METHODS

A retrospective analysis was completed using the 2016 National Surgical Quality Improvement Program (NSQIP) database to identify patients with obesity (Body Mass Index (BMI) ≥ 30 kg/m²) who underwent LUHR or OUHR. Patients were divided into OUHR and LUHR groups, and post-operative outcomes were compared, focusing on wound complications.

RESULTS

A total of 12,026 patients with obesity who underwent umbilical hernia repair were identified; 9695 underwent OUHR, while 2331 underwent LUHR. The LUHR group was found to have a statistically significant higher BMI (37.5 kg/m² vs. 36.1 kg/m²; p < 0.01) and higher incidence of diabetes mellitus requiring therapy (18.4% vs. 15.8%; p < 0.01), hypertension (47.5% vs. 43.8%; p < 0.01), and current smoker status (18.6% vs. 16.5%; p < 0.02). Superficial surgical site infection (SSI) was significantly higher in the OUHR group (1.5% vs. 0.9%; p < 0.03), and there was a trend towards higher deep SSI in the OUHR group (0.3% vs. 0.5%; p = 0.147). There was no difference in organ space SSI, wound disruption, or return to OR. On logistic regression, composite SSI rate (defined as superficial, deep, and organ space SSIs) was significantly increased in the OUHR group (p < 0.01). Predictive factors significantly associated with increased morbidity included female gender and higher BMI.

CONCLUSIONS

In patients with obesity, even though the LUHR group had an overall higher BMI and higher rates of diabetes, hypertension, and current smoking status, they experienced decreased post-operative wound complications compared to the OUHR group.

Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer

AIM

The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes.

METHOD

We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission.

RESULTS

During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors.

CONCLUSIONS

For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.

Fruitful first experience with an 8K ultra-high-definition endoscope for laparoscopic colorectal surgery

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

Sociodemographic and behavioral characteristics associated with blood donation in the United States: a population-based study

BACKGROUND

Contemporary population-based data on characteristics associated with blood donation in the United States (U.S.) are limited.

STUDY DESIGN AND METHODS

A cross-sectional analysis was performed among 28,739 persons aged 18 years and older who participated in the 2016 National Health Interview Survey, a household survey of the noninstitutionalized U.S. civilian population. Analyses were weighted and accounted for the complex survey design. Adjusted prevalence ratios (aPR) were estimated by multivariable log-binomial regression.

RESULTS

The percentage of individuals reporting a past-year history of blood donation was 5.7% (95% confidence interval [CI], 5.3%-6.1%) and was highest in the youngest age group (18-24 years, 8.4%). A past-year history of blood donation was more common in males compared to females (6.3% vs. 5.1%; aPR, 1.12 [95% CI, 0.99-1.27]) and those born in the U.S. compared to individuals born outside the U.S. (6.4% vs. 2.4%; aPR, 1.92 [95% CI, 1.49-2.47]). The percentage of individuals with a past-year history of blood donation was significantly lower in blacks (3.9%; aPR, 0.60 [95% CI, 0.47-0.75]) and Hispanics (3.0%; aPR, 0.63 [95% CI, 0.48-0.83]) in comparison to whites (6.9%). Being a college graduate, being employed, being physically active, and never being a cigarette smoker were factors positively associated with blood donation. The percentage of individuals with a past-year history of blood donation varied by geographic census region, with prevalence being higher in the Midwest (7.3%) and South (6.0%) compared to the Northeast (4.7%) and West (4.4%).

CONCLUSION

Continued differences in the blood donor population with reference to the U.S. population underscore the need to understand barriers or deterrents to blood donation. Evidence-based donor recruitment and related policies remain imperative to ensure that there is a sustainable blood supply.

The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer

BACKGROUND

In an attempt to prevent overly aggressive treatment of low-risk thyroid cancers, the American Thyroid Association changed guideline recommendations in late 2015 to state that either hemithyroidectomy or total thyroidectomy are acceptable operations for these patients. We hypothesized that surgeons would increasingly perform hemithyroidectomy after the release of these guidelines.

METHODS

The database of the National Surgery Quality Improvement Program was queried to identify all patients with thyroid cancer who were undergoing thyroidectomy between 2009 and 2017. Patients treated before the release of the 2015 American Thyroid Association guidelines were compared with those treated afterward. Temporal trends in operative rates were assessed quarterly using interrupted time series analyses.

RESULTS

A total of 35,291 patients were included in the study. Of those, 26,882 (76.2%) were female and 25,193 (71.3%) were white. After the release of the American Thyroid Association guidelines, there was an increase in hemithyroidectomy rate for patients with cancer from 17.3% to 22.0% (P < .001). Interrupted time series analysis controlling for patient factors demonstrated that quarterly growth in the hemithyroidectomy rate accelerated almost 10-fold (P < .001) after publication of the revised guidelines. Of note, there was no corresponding increase in the completion thyroidectomy rate (8.3% versus 7.9%, respectively, P = .213). Patients treated with hemithyroidectomy were more likely to be managed as outpatients (70.8% versus 57.1%, P < .001), had fewer surgical site infections (0.3% versus 0.5%, P = .050), and had fewer unplanned reintubations (0.2% versus 0.4%, P = .005).

CONCLUSION

In hospitals participating in the National Surgery Quality Improvement Program, the hemithyroidectomy rate increased significantly after the release of the 2015 American Thyroid Association guidelines. Surgeons at hospitals that participate in the National Surgery Quality Improvement Program may be changing practice patterns in response to these guidelines.

GI Surgical Emergencies: Scope and Burden of Disease

Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.

Low-Cost Laparoscopic Skill Training for Medical Students Using Homemade Equipment

INTRODUCTION

Despite the increasing prevalence of minimally invasive surgery (MIS), medical students receive little training in MIS techniques like laparoscopy. Cost is perhaps the biggest obstacle, as expensive laparoscopic skill simulators (box trainers) are needed to mimic the laparoscopic environment. Low-cost, homemade box trainers have been built and described in the literature but are generally relegated to self-directed practice for surgical residents. These do-it-yourself (DIY) box trainers are uniquely capable of addressing cost as a major barrier to laparoscopic skills training for medical students but have not previously been used specifically for this purpose.

METHODS

Students from the Oakland University William Beaumont School of Medicine (n = 17) participated in a laparoscopic skills training course using DIY box trainers. Four basic laparoscopic tasks were taught using live demonstrations followed by directed practice. Learners were instructed to record their first and last attempts in order to enable self-assessment of their progress.

RESULTS

All learners were able to successfully complete each of the four laparoscopic tasks by the end of their respective sessions. Feedback from the learners in the form of a postsession survey indicated that the course provided an enjoyable and high-quality experience.

DISCUSSION

This resource is effective at providing medical students with a low-cost opportunity to experience laparoscopy and develop basic laparoscopic skills.

Retrospective analysis of the association between intraoperative magnesium sulfate infusion and postoperative acute kidney injury after major laparoscopic abdominal surgery

Magnesium sulfate can be used as a co-adjuvant drug during the perioperative period and has multiple benefits. Recent evidence suggested that perioperative magnesium sulfate infusion may lower the risk of postoperative acute kidney injury (AKI). We investigated the association between intraoperative magnesium sulfate infusion and incidence of AKI after major laparoscopic abdominal surgery. We retrospectively analyzed the medical records of adult patients 20 years or older who underwent elective major laparoscopic abdominal surgery (>2 hours) between 2010 and 2016. We investigated the association between intraoperative magnesium sulfate infusion and the incidence of postoperative AKI until postoperative day (POD) 3 using a multivariable logistic regression analysis. We included 3,828 patients in this analysis; 357 patients (9.3%) received an intraoperative magnesium sulfate infusion and 186 patients (4.9%) developed postoperative AKI by POD 3. A multivariable logistic regression analysis showed that magnesium infusion was associated with a significant decrease (63%) in postoperative AKI (odds ratio, 0.37; 95% confidence interval, 0.14–0.94; P = 0.037). Our study suggested that intraoperative magnesium sulfate infusion is associated with a reduced risk of postoperative AKI until POD 3 for patients who underwent laparoscopic major abdominal surgery. Well-designed, prospective studies should be conducted to further substantiate these findings.

Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.

30-Day Outcomes of Laparoscopic Versus Open Total Proctocolectomy with Ileoanal Anastomosis in Children and Young Adults: A Combined Analysis of the National Surgical Quality Improvement Project Pediatric and Adult Databases

BACKGROUND

Studies comparing pediatric laparoscopic and open total proctocolectomy with ileoanal anastomosis (TPC-IAA) are limited in size and number. This study utilized the adult and pediatric databases of the National Surgical Quality Improvement Project (NSQIP) to evaluate 30-day outcomes of these two techniques.

MATERIALS AND METHODS

Patients younger than 21 years who underwent TPC-IAA from 2012 to 2016 were identified in both NSQIP databases. Simple and multivariate logistic regression was used to compare risk of reoperation, readmission, and postoperative occurrences between laparoscopic and open groups. Cox regression was used to evaluate length of stay (LOS).

RESULTS

A total of 440 cases were identified, of which 421 (95.7%) were elective. Median age in the elective group was 15.8 years (interquartile range 13-18). Diagnoses included inflammatory bowel disease (47%), benign neoplasm (42%), and Hirschsprung disease (6%). The laparoscopic group (67.5%, n = 139) had shorter median postoperative LOS (6 versus 8 days, P < .001) and decreased incidence of pulmonary complications (risk ratio [RR] 0.09; CI: 0.01-0.80, P = .031) and superficial surgical site infections (SSI) (RR 0.30; 95% CI: 0.10-0.88, P = .028). Median operative time was shorter (4.6 versus 5.1 hours, P = .013) and risk of organ space SSI was lower (RR = 0.11, 95% CI: 0.01-0.80, P = .037) in the open group (n = 282). Rates of 30-day readmission and reoperation were similar between groups.

CONCLUSIONS

In the first study to utilize data from both the pediatric and adult NSQIP databases, resulting in the largest pediatric sample of TPC-IAA to date, we found that 67.5% of elective cases were performed laparoscopically, the highest reported in a multi-institutional pediatric study, indicating increasing comfort with advanced laparoscopic techniques among pediatric surgeons. The laparoscopic approach resulted in shorter postoperative LOS and decreased risk of superficial SSI, whereas the open approach was associated with shorter operative time and lower risk of organ space SSI.

Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study

BACKGROUND

MIS utilization for inguinal hernia repair is low compared to in other procedures. The impact of low adoption in surgeons is unclear, but may affect regional access to minimally invasive surgery (MIS). We explored the impact of surgeon MIS utilization in inguinal hernia repair across a statewide population.

METHODS

We analyzed 6723 patients undergoing elective inguinal hernia repair from 2012 to 2016 in the Michigan Surgical Quality Collaborative. The primary outcome was surgeon MIS utilization. The geographic distribution of high MIS-utilizing surgeons was compared across Hospital Referral Regions using Pearson's Chi-squared test. Hierarchical logistic regression was used to identify patient and hospital factors associated with MIS utilization.

RESULTS

Surgeon MIS utilization varied, with 58% of 540 surgeons performing no MIS repair. For the remaining surgeons, MIS utilization was bimodally distributed. High-utilization surgeons were unevenly distributed across region, with corresponding differences in regional MIS rate ranging from 10 to 48% (p < 0.001). MIS was used in 41% of bilateral and 38% of recurrent hernia. MIS repair was more likely with higher hospital volume and less likely for patients aged 65+ (OR 0.68, p = 0.003), black patients (OR 0.75, p = 0.045), patients with COPD (OR 0.57, p < 0.001), and patients in ASA class > 3 (OR 0.79 p < 0.001).

CONCLUSIONS

MIS utilization varies between surgeons, likely driving differences in regional MIS rates and leading to guideline-discordant care for patients with bilateral or recurrent hernia. Interventions to reduce this practice gap could include training programs in MIS repair, or regionalization of care to improve MIS access.