Impact of Coronavirus Disease 2019 on Clinical Outcomes of Robotic Cholecystectomy.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic strained the health care sector, putting severe constraints on surgical departments. In this study, we evaluate the impact of the pandemic on the outcomes of patients undergoing robotic cholecystectomy (RC). PATIENTS AND METHODS: Patients who underwent RC 1 year before and after March 2020 were included in this retrospective study and assigned accordingly to the pre or post-COVID group. Pre, intra, and postoperative variables were compared between groups. RESULTS: In total, 110 patients were assigned to the pre-COVID group versus 80 in the post-COVID group. There were no differences in the demographics, except for a higher rate of previous gallbladder disease in the pre-COVID group (35.5% vs 13.8,% P < 0.001). The post-COVID group had a higher rate of emergent RCs (62.5% vs 39.1%, P = 0.002). Operative times were greater in the post-COVID group due to the more frequent participation of clinical fellows in the cases. The median hospital length of stay for both groups was 1 day, with higher rates of same-day discharge (pre-COVID 40.9% vs post-COVID 57.5%, P = 0.028). Complications were comparable between both groups, with no recorded cases of COVID-19 contraction within the virus incubation period. The median follow-up was 10 months for the entire cohort. CONCLUSION: During the COVID-19 pandemic, an increase in emergent cases, as well as higher rates of same-day discharge, were recorded, with no impact on postoperative outcomes in patients undergoing RC.

Learning Curve of Multiport Robotic Cholecystectomy: A Cumulative Sum Analysis.

OBJECTIVE: To establish the learning curve of multiport robotic cholecystectomy (MRC). PATIENTS AND METHODS: A retrospective analysis of patients undergoing MRC was performed. A cumulative sum analysis helped define the learning curve through the evaluation of skin-to-skin (STS) time and postoperative complications rate. Direct comparison of variables was conducted between the phases. RESULTS: Two hundred forty-five MRC cases were included. Average STS and console times were 50.6 and 29.9 minutes, respectively. Cumulative sum analysis established 3 phases with inflection points at cases 84th and 134th. A significant decrease in STS time was observed between the phases. Middle and late phases encompassed patients with higher comorbidities. Two conversions to open were recorded in the early phase. Postoperative complication rates were comparable among the early (2.5%), middle (6.8%), and late (5.6%) phases ( P = 0.482). CONCLUSION: A steady decrease in STS time was observed across the 3 different phases established at the 84th and 134th patients.

Do the outcomes of robotic cholecystectomy in elderly worsen with age?

The elderly population are at an increased risk of perioperative morbidity and mortality due to their disease profile. Minimally invasive surgery and in particular the robotic approach may improve the outcomes of cholecystectomy in the elderly. Patients who underwent robotic cholecystectomy (RC) and were older than 65 at the time of the procedure were included in this retrospective study. Pre-, intra-, and postoperative variables of the whole cohort were initially reported and then compared between three different age ranges. In total, 358 elder patients were included. Mean age ± Standard deviation was 74.5 ± 6.9 years. Males constituted 43% of the cohort. American Society of Anesthesiologists (ASA) scores were mostly ASA-3 (64%). One hundred and fifty-seven (43.9%) were emergent procedures. Conversion to open surgery rate was 2.2%. Median hospital length of stay was 2 days. With a mean follow-up of 28 months, overall complication rate was 12.3%. After subdividing into three age groups (A:65-69; B:70-79; C:80 +), we noticed significantly higher comorbidities in group C. Same-day discharge was lower in the older patients. However, overall complications and conversion to open remained comparable between the three groups. This is the first study to investigate the outcomes of RC in patients older than 65. RC provided low conversion and complication rates, that are also comparable between the different age ranges, despite the higher comorbidities in patients older than 80.

Learning Curve of Single-site Robotic Cholecystectomy: A Cumulative Sum Analysis.

BACKGROUND: Minimally invasive surgery has significantly improved cosmesis and clinical outcomes after either laparoscopic or robotic cholecystectomy. In an effort to minimize the number of incisions in multiport procedures, single-site approaches have been developed. However, single-site robotic cholecystectomy (SSRC) can be technically challenging for novice surgeons. The goal of this study is to establish the learning curve (LC) of SSRC through an assessment of operative times and clinical outcomes. MATERIALS AND METHODS: A retrospective analysis of patients undergoing SSRC over a period of 5 years was performed. Consecutive cholecystectomy cases were assessed based on the procedure setting (elective vs. emergent). Cumulative sum analysis were used to establish the LC through an evaluation of the skin-to-skin (STS) time and postoperative complications rate. Afterward, a direct comparison was performed between the established phases. RESULTS: This study included a total of 259 SSRCs with an overall mean STS time of 41.1 minutes. Elective cases took on average of 38.8 minutes, whereas emergent cases spanned over 60.5 minutes ( P= 0.005). The cumulative sum-LC was obtained by summing the differences between each procedure's STS time, revealing a quadratic best-fit line maximum and an inflection point between the early and late phases at case 91. A significant difference between STS time was seen between the early and late phases (53.8 vs. 30.0 min, P< 0.0001). There were no significant differences in terms of postoperative complications between the 2 phases. Incisional hernia rates were comparable between the 2 phases (early: 4.4% vs. late: 2.5%, P< 0.461). CONCLUSIONS: This is the largest study to assess the LC of SSRC through operative time and clinical outcomes. A steady decrease in STS time was observed during the completion of the first 91 consecutive cases.

Obesity and mid-term outcomes following robotic cholecystectomy.

BACKGROUND: As obese adults often suffer from gallbladder disease, more data on postoperative outcomes following robotic cholecystectomy(RC) is needed. METHODS: RC candidates with a body mass index(BMI) > 30 kg/m2 were included. Postoperative course was documented and analyzed. A logistic regression analysis was performed to determine possible risk factors associated with complications. RESULTS: 617 patients with a BMI of 35.9 ± 6.4 kg/m2 were included of which 65 had complicated gallbladders (gangrenous, fistulated, or abscessed). Eight cases were converted to open. Sixty-five(10.5%) patients revisited the emergency department within 30 days, and 35(5.7%) were readmitted to the hospital. Average follow-up time was 35 months. Fifty(9.1%) patients experienced complications, eight(1.5%) underwent reoperation. Postoperative complications were associated with chronic obstructive pulmonary disease[p < 0.001, Odds-Ratio(OR):8.418, 95%-Confidence-interval(CI):4.029-17.585], BMI(p < 0.024, OR:1.045, 95%-CI:[1.006-1.086]), class-III obesity (p < 0.021, OR:2.221, 95%-CI:[1.126-4.379], and complicated gallbladders (p < 0.001, OR:3.659, 95%CI:[1.665-8.041]). CONCLUSION: This is the first study to establish a link between higher obesity classes and postoperative complications following RC.

Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension.

BACKGROUND: Intubation in hypotensive emergency department (ED) patients may increase the risk of life-threatening complications such as hypoperfusion and cardiovascular collapse. Peripherally administered, diluted "push-dose" phenylephrine has been advocated to treat peri-intubation hypotension, however, its effectiveness is unknown. STUDY OBJECTIVE: To investigate the efficacy and usage patterns of bolus-dose phenylephrine for peri-intubation hypotension at an academic medical center. METHODS: A retrospective chart review of all adult intubated, hypotensive patients (systolic blood pressure [SBP] < 90 mm Hg) over 12 months was conducted. During the peri-intubation period (30-min prior to/after intubation), the effect of phenylephrine was evaluated pre/post drug administration by comparing SBP, diastolic blood pressure (DBP), and heart rate (HR). RESULTS: A total of 119 patients met eligibility criteria. Phenylephrine was given to 29/119 (24%) patients and 20 (17%) were treated during the peri-intubation period. Phenylephrine was given for many different conditions, and treatment timing varied greatly. Phenylephrine was given with other vasopressors 70% of the time (14/20), however, the timing of vasopressor infusion also varied greatly. When phenylephrine was given during the peri-intubation period, there were significant increases in SBP and DBP (p < 0.01) with no change in HR. CONCLUSION: In this academic ED, bolus-dose phenylephrine was used by practitioners without a systematic pattern. Although phenylephrine improved hemodynamics, it is possible that nonsystematic use of phenylephrine may cause inadvertent negative effects. Further studies will need to be conducted to better understand the best practices for use of phenylephrine.