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Dugan MM, Ross S, Christodoulou M, Pattilachan TM, Flores JA, Rosemurgy A, Sucandy I. Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study. Am J Surg 2024:S0002-9610(24)00175-2. [PMID: 38519401 DOI: 10.1016/j.amjsurg.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. METHODS The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. RESULTS Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p = 0.01), increased Child-Pugh score (p < 0.01), and R1 margin status (p = 0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p = 0.045). Readmissions didn't significantly impact five-year survival (p = 0.42) but increased fixed indirect hospital costs (p < 0.01). CONCLUSIONS Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.
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Affiliation(s)
- Michelle M Dugan
- Florida Atlantic University Schmidt College of Medicine, USA; Digestive Health Institute AdventHealth Tampa, USA
| | - Sharona Ross
- Digestive Health Institute AdventHealth Tampa, USA
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M’Koma AE. Inflammatory Bowel Disease: Clinical Diagnosis and Surgical Treatment-Overview. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:567. [PMID: 35629984 PMCID: PMC9144337 DOI: 10.3390/medicina58050567] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 12/18/2022]
Abstract
This article is an overview of guidelines for the clinical diagnosis and surgical treatment of predominantly colonic inflammatory bowel diseases (IBD). This overview describes the systematically and comprehensively multidisciplinary recommendations based on the updated principles of evidence-based literature to promote the adoption of best surgical practices and research as well as patient and specialized healthcare provider education. Colonic IBD represents idiopathic, chronic, inflammatory disorders encompassing Crohn's colitis (CC) and ulcerative colitis (UC), the two unsolved medical subtypes of this condition, which present similarity in their clinical and histopathological characteristics. The standard state-of-the-art classification diagnostic steps are disease evaluation and assessment according to the Montreal classification to enable explicit communication with professionals. The signs and symptoms on first presentation are mainly connected with the anatomical localization and severity of the disease and less with the resulting diagnosis "CC" or "UC". This can clinically and histologically be non-definitive to interpret to establish criteria and is classified as indeterminate colitis (IC). Conservative surgical intervention varies depending on the disease phenotype and accessible avenues. The World Gastroenterology Organizations has, for this reason, recommended guidelines for clinical diagnosis and management. Surgical intervention is indicated when conservative treatment is ineffective (refractory), during intractable gastrointestinal hemorrhage, in obstructive gastrointestinal luminal stenosis (due to fibrotic scar tissue), or in the case of abscesses, peritonitis, or complicated fistula formation. The risk of colitis-associated colorectal cancer is realizable in IBD patients before and after restorative proctocolectomy with ileal pouch-anal anastomosis. Therefore, endoscopic surveillance strategies, aimed at the early detection of dysplasia, are recommended. During the COVID-19 pandemic, IBD patients continued to be admitted for IBD-related surgical interventions. Virtual and phone call follow-ups reinforcing the continuity of care are recommended. There is a need for special guidelines that explore solutions to the groundwork gap in terms of access limitations to IBD care in developing countries, and the irregular representation of socioeconomic stratification needs a strategic plan for how to address this serious emerging challenge in the global pandemic.
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Affiliation(s)
- Amosy Ephreim M’Koma
- Department of Biochemistry, Cancer Biology, Neuroscience and Pharmacology, Meharry Medical College School of Medicine, Nashville, TN 37208-3500, USA; or ; Tel.: +1-615-327-6796; Fax: +1-615-327-6440
- Department of Pathology, Anatomy and Cell Biology, Meharry Medical College School of Medicine, Nashville General Hospital, Nashville, TN 37208-3599, USA
- Division of General Surgery, Section of Colon and Rectal Surgery, Vanderbilt University School of Medicine, Nashville, TN 37232-0260, USA
- The American Society of Colon and Rectal Surgeons (ASCRS), 2549 Waukegan Road, #210, Bannockburn, IL 600015, USA
- The American Gastroenterological Association (AGA), Bethesda, MD 20814, USA
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Kang E, Shin JI, Griesemer AD, Lobritto S, Goldner D, Vittorio JM, Stylianos S, Martinez M. Risk Factors for 30-Day Unplanned Readmission After Hepatectomy: Analysis of 438 Pediatric Patients from the ACS-NSQIP-P Database. J Gastrointest Surg 2021; 25:2851-2858. [PMID: 33825121 DOI: 10.1007/s11605-021-04995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/23/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic resections are uncommon in children. Most studies reporting complications of these procedures and risk factors associated with unplanned readmissions are limited to retrospective data from single centers. We investigated risk factors for 30-day unplanned readmission after hepatectomy in children using the American College of Surgeons National Surgical Quality Improvement-Pediatric database. METHODS The database was queried for patients aged 0-18 years who underwent hepatectomy for the treatment of liver lesions from 2012 to 2018. Chi-squared tests were performed to evaluate for potential risk factors for unplanned readmissions. A multivariate regression analysis was performed to identify independent predictors for unplanned 30-day readmissions. RESULTS Among 438 children undergoing hepatectomy, 64 (14.6%) had unplanned readmissions. The median age of the hepatectomy cohort was 1 year (0-17); 55.5% were male. Patients readmitted had significantly higher rates of esophageal/gastric/intestinal disease (26.56% vs. 14.97%; p=0.022), current cancer (85.94% vs. 75.67%; p=0.012), and enteral and parenteral nutritional support (31.25% vs. 17.65%; p=0.011). Readmitted patients had significantly higher rates of perioperative blood transfusion (67.19% vs. 52.41%; p=0.028), organ/space surgical site infection (10.94% vs. 1.07%; p<.001), sepsis (15.63% vs. 3.74%; p<.001), and total parenteral nutrition at discharge (9.09% vs. 2.66%; p=0.041). Organ/space surgical site infection was an independent risk factor for unplanned readmission (OR=9.598, CI [2.070-44.513], p=0.004) by multivariable analysis. CONCLUSION Unplanned readmissions after liver resection are frequent in pediatric patients. Organ/space surgical site infections may identify patients at increased risk for unplanned readmission. Strategies to reduce these complications may decrease morbidity and costs associated with unplanned readmissions.
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Affiliation(s)
- Elise Kang
- Department of Pediatrics, NewYork Presbyterian Hospital, New York, NY, USA
| | - John Inho Shin
- Department of Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Adam D Griesemer
- Department of Surgery, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Steven Lobritto
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Dana Goldner
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Jennifer M Vittorio
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Steven Stylianos
- Department of Surgery, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY, USA.
- Department of Pediatrics, Columbia University Irving Medical Center, 620 West 168th Street, PH17, Room 105B, New York, NY, 10032, USA.
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de Klein GW, Brohet RM, Liem MSL, Klaase JM. Possible Preventable Causes of Unplanned Readmission After Elective Liver Resection, Results from a Non-academic Referral HPB Center. World J Surg 2019; 43:1802-1808. [PMID: 30843099 DOI: 10.1007/s00268-019-04970-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes. METHODS In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive. RESULTS In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission-with an odds ratio of 4.69 (CI 2.41-9.12, p < 0.001). CONCLUSION Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.
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Affiliation(s)
- G W de Klein
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - R M Brohet
- Department of Research and Innovation, Isala, Zwolle, The Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
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Lillemoe HA, Marcus RK, Day RW, Kim BJ, Narula N, Davis CH, Gottumukkala V, Aloia TA. Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids. Surgery 2019; 166:22-27. [PMID: 31103198 PMCID: PMC6579699 DOI: 10.1016/j.surg.2019.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake. METHODS For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. RESULTS Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001). CONCLUSION The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.
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Affiliation(s)
- Heather A Lillemoe
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Rebecca K Marcus
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Ryan W Day
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Bradford J Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Nisha Narula
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Catherine H Davis
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston.
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