Great Debates: Surgery or Watch and Wait After Total Neoadjuvant Therapy for Rectal Cancer.

Locally advanced rectal cancer has traditionally been treated with multimodal therapy including neoadjuvant chemoradiotherapy followed by surgical resection. More recent data suggests that in appropriate patients, total neoadjuvant treatment (TNT) makes it possible to adopt a "watch and wait" approach. Advocates for watch and wait argue that patients with a complete or near-complete clinical response to TNT have comparable overall and disease-free survival to their counterparts who undergo surgical resection, and also have a better quality of life, fewer complications, and potentially avoid a stoma. The dogma of surgery as regional curative intent therapy has been challenged by similar recurrence rates among those treated with total mesorectal excision (TME) and those treated with watch and wait. Furthermore, those who develop local recurrence in the watch and wait groups are equally salvageable, either by surgery, brachytherapy, or chemotherapy. While watch and wait is not appropriate in all patients, this manuscript highlights the benefits and drawbacks of both therapeutic modalities.

Outcomes of Colectomy and Proctectomy According to Surgeon Training: General vs Colorectal Surgeons.

BACKGROUND: Colectomies and proctectomies are commonly performed by both general surgeons (GS) and colorectal surgeons (CRS). The aim of our study was to examine the outcomes of elective colectomy, urgent colectomy, and elective proctectomy according to surgeon training. STUDY DESIGN: Data were obtained from the Vizient database for adults who underwent elective colectomy, urgent colectomy, and elective proctectomy from 2020 to 2022. Operations performed in the setting of trauma and patients within the database's highest relative expected mortality risk group were excluded. Outcomes were compared according to surgeon's specialty: GS vs CRS. The primary outcome was in-hospital mortality. The secondary outcome was in-hospital complication rate. Data were analyzed using multivariate logistic regression. RESULTS: Of 149,516 elective colectomies, 75,711 (50.6%) were performed by GS and 73,805 (49.4%) by CRS. Compared with elective colectomies performed by CRS, elective colectomies performed by GS had higher rates of complications (4.9% vs 3.9%, odds ratio [OR] 1.23, 95% CI 1.17 to 1.29, p < 0.01) and mortality (0.5% vs 0.2%, OR 2.06, 95% CI 1.72 to 2.47, p < 0.01). Of 71,718 urgent colectomies, 54,680 (76.2%) were performed by GS, whereas 17,038 (23.8%) were performed by CRS. Compared with urgent colectomies performed by CRS, urgent colectomies performed by GS were associated with higher rates of complications (12.1% vs 10.4%, OR 1.14, 95% CI 1.08 to 1.20, p < 0.01) and mortality (5.1% vs 2.3%, OR 2.08, 95% CI 1.93 to 2.23, p < 0.01). Of 43,749 elective proctectomies, 28,458 (65.0%) were performed by CRS and 15,291 (35.0%) by GS. Compared with proctectomies performed by CRS, those performed by GS were associated with higher rates of complications (5.3% vs 4.4%, OR 1.16, 95% CI 1.06 to 1.27, p < 0.01) and mortality (0.3% vs 0.2%, OR 1.49, 95% CI 1.02 to 2.20, p = 0.04). CONCLUSIONS: In this nationwide study, colectomies and proctectomies performed by CRS were associated with improved outcomes compared with GS. Hospitals without a CRS on staff should consider prioritizing recruiting CRS specialists.

Short- and long-term survival after laparoscopic versus open total gastrectomy for gastric adenocarcinoma: a National database study.

BACKGROUND: The use of laparoscopic total gastrectomy for gastric cancer remains controversial. Our objective was to compare outcomes of laparoscopic total gastrectomy (LTG) vs. open total gastrectomy (OTG) for gastric adenocarcinoma using a national cancer database. METHODS: The National Cancer Database (2010-2014) was analyzed for total gastrectomy cases performed for gastric adenocarcinoma. Patient demographics and surgical outcomes were stratified by stage and compared based on laparoscopic vs. open surgical approach. Primary outcome measures included 30-day and 90-day mortality and Kaplan-Meier curves to estimate long-term survival. RESULTS: There were 2584 cases analyzed, including 592 (22.9%) stage I, 710 (27.5%) stage II, and 1282 (49.6%) stage III cases. The distribution of LTG vs. OTG cases was 156 (26.4%) vs. 436 (73.6%) for stage I, 163 (23.0%) vs. 547 (77.0%) for stage II, and 241 (18.8%) vs. 1041 (81.2%) for stage III. For all stages analyzed, there was no difference between laparoscopic vs. open approach for adjusted 30-day mortality (stage I: adjusted odds ratio (AOR) 0.52, p = 0.75; stage II: AOR 1.36, p > 0.99; stage III: AOR 0.46, p = 0.29) or 90-day mortality (stage I: AOR 0.46, p = 0.99; stage II: AOR 1.17, p = 0.99; stage III: 0.57, p = 0.29). There was no difference between LTG vs. OTG 5-year Kaplan-Meier estimated survival curves for any stage (stage I: p = 0.20; stage II: p = 0.83; stage III: p = 0.46). When compared to OTG, LTG had a similar hazard ratio (HR) for mortality (HR 0.89 p = 0.20). CONCLUSIONS: Laparoscopic total gastrectomy and OTG have comparable 30-day mortality, 90-day mortality, and long-term survival.

Improved survival with adjuvant chemotherapy in locally advanced rectal cancer patients treated with preoperative chemoradiation regardless of pathologic response.

OBJECTIVE: The aim of this study is to examine the effect of postoperative chemotherapy on survival in patients with stage II or III rectal adenocarcinoma who undergo neoadjuvant chemoradiation (CRT) and surgical resection. METHODS: A retrospective review of the National Cancer Database (NCDB) from 2006 to 2013 was performed. Cases were analyzed based on pathologic complete response (pCR) status and use of adjuvant therapy. The Kaplan-Meier method was used to estimate overall survival probabilities. RESULTS: 23,045 cases were identified, of which 5832 (25.31%) achieved pCR. In the pCR group, 1513 (25.9%) received adjuvant chemotherapy, and in the non-pCR group, 5966 (34.7%) received adjuvant therapy. In the pCR group, five-year survival probability was 87% (95% CI 84%-89%) with adjuvant therapy and 81% (95% CI 79%-82%) without adjuvant therapy. In the non-pCR group, five-year survival probability was 78% (95% CI 76%-79%) with adjuvant therapy and 70% (95% CI 69%-71%) without adjuvant therapy. In the non-pCR and node-negative subgroup (ypN-), five-year survival probability was 86% (95% CI 84%-88%) with adjuvant therapy and 76% (95% CI 74%-77%) without adjuvant therapy. In the non-pCR and node-positive subgroup (ypN+), five-year survival probability was 67% (95% CI 65%-70%) with adjuvant therapy and 60% (95% CI 58%-63%) without adjuvant therapy. CONCLUSIONS: Adjuvant chemotherapy in stage II or III rectal adenocarcinoma is associated with increased five-year survival probability regardless of pCR status. We observed similar survival outcomes among non-pCR ypN- treated with adjuvant chemotherapy compared with patients achieving pCR treated with adjuvant chemotherapy.

Locoregional Anesthesia Offers Improved Outcomes after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: General anesthesia (GA) and locoregional anesthesia (LA) are two anesthetic options for endovascular repair of ruptured abdominal aortic aneurysms (REVAR). Studies on elective endovascular repair of nonruptured aneurysms have indicated that in select patients, LA may provide improved outcomes compared with GA. We aimed to examine the 30-day outcomes in patients undergoing REVAR using GA and LA in a contemporary nationwide cohort of patients presenting with ruptured abdominal aortic aneurysms. METHODS: Patients who underwent REVAR using GA and LA from January 2011 through December 2015, inclusively, were studied in the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)-targeted EVAR database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and 30-day postoperative outcomes between the two groups. RESULTS: Six-hundred ninety patients were identified to have undergone REVAR from 2011 to 2015, of which 12.5% (86) were performed under LA. For the entire cohort, the mean age was 74.3 years, and 80% were male. Mean aneurysm size was 7.6 cm and did not differ between the two anesthetic groups. Major comorbidities were similar between both groups, except a slightly higher rate of congestive heart failure in the LA group (7.0% vs. 2.5%, P = 0.02). Proximal or distal aneurysm extent also did not differ between the two groups. There was a significantly higher rate of bilateral percutaneous access in the LA group (59.3% vs. 25.2%, P < 0.01). REVAR under LA had shorter mean operative time (132 vs. 166 min, P < 0.01) and lower rate of concomitant lower extremity revascularization (2.3% vs. 10.6%, P < 0.01). There were no differences in need for perioperative transfusion or any other adjunctive procedures. Ultimately, 30-day mortality was significantly lower in the LA group (16.3% vs. 25.2%, P < 0.01). This difference was more pronounced in the subgroup of patients with hemodynamic instability (15.4% vs. 39.4%, P < 0.01). The LA group also demonstrated significantly shorter intensive care unit (ICU) length of stay (3.0 vs. 5.0 days, P = 0.01) and low rates of postoperative pneumonia (3.5% vs. 10.9%, P = 0.03). After adjustment for demographics, comorbid conditions, hypotensive status, and aneurysm characteristics, there was a two-fold higher mortality in patients undergoing REVAR using GA versus LA, with a four-fold increase in the hemodynamically unstable cohort. CONCLUSIONS: The ACS NSQIP-targeted EVAR database shows that LA is used in only 12.5% of patients undergoing REVAR in this nationwide cohort. This rate does not change when examining the subset of patients who are hemodynamically unstable. Other benefits include shorter ICU lengths of stay and lower rates of pneumonia. These data suggest that LA should be considered in patients undergoing REVAR, regardless of hemodynamic instability.

Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost.

BACKGROUND: Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal. METHODS: A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes. RESULTS: Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00). CONCLUSION: Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.

eFAST for Pneumothorax: Real-Life Application in an Urban Level 1 Center by Trauma Team Members.

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

Comparison of percutaneous versus open femoral cutdown access for endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Ruptured endovascular aortic aneurysm repair (REVAR) is being increasingly used to treat ruptured abdominal aortic aneurysms (rAAAs). However, the comparison between totally percutaneous (pREVAR) vs femoral cutdown (cREVAR) access for REVAR has not been studied. We used a national surgical database to evaluate the 30-day outcomes in patients undergoing pREVAR vs cREVAR. METHODS: Patients who underwent EVAR for rAAA between 2011 and 2014, inclusively, were studied in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and postoperative outcomes between those who had pREVAR and cREVAR. RESULTS: We identified 502 patients who underwent REVAR, of which 129 had pREVAR (25.7%) and 373 cREVAR (74.3%). Between 2011 and 2014, the use of totally percutaneous access for repair increased from 14% to 32%. Of all patients undergoing REVAR, 24% had bilateral percutaneous access, 2% had attempted percutaneous access converted to cutdown, 64% had bilateral femoral cutdowns, and 10% had single femoral cutdown. Univariate analysis showed there were no significant differences in age, gender, body mass index, AAA size, or other high-risk physiologic comorbidities between the two groups. There was also no difference in rates of preoperative hemodynamic instability (48.1% vs 45.0%; P = .55) or need for perioperative transfusion (67.4% vs 67.8%; P = .94). There was a higher incidence of use of regional anesthesia for pREVAR compared with cREVAR (20.9% vs 7.8%; P < .01). The incidence of postoperative wound complications was similar between both groups (4.8% vs 5.4%; P = .79), whereas hospital length of stay was shorter in the pREVAR group (mean difference, 1.3 days). Overall 30-day mortality was higher in the pREVAR group (28.7% vs 20.1%; P = .04), and operative time was longer (mean difference, 6.3 minutes). However, when pREVARs done in 2011 to 2012 were compared with those done in 2013 to 2014, 30-day mortality decreased from 38.2% to 25.3% and operative time decreased by 25 minutes (188 to 163 minutes). Multivariate analysis showed there were no significant differences in mortality, wound complications, hospital length of stay, or operative time between pREVAR and cREVAR. CONCLUSIONS: The ACS NSQIP targeted vascular database shows that there has been increased adoption of pREVAR in recent years, with improved mortality and operative time over the 4-year study period. At this point, pREVAR has not yet been shown to be superior to cREVAR for rAAA, but these outcome improvements are encouraging and likely attributable to increased operator experience.

Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease.

OBJECTIVE: Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI). METHODS: Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently. RESULTS: From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P < .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB. CONCLUSIONS: In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC.

Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

BACKGROUND: The role of fecal diversion with pelvic anastomosis during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is not well defined. METHODS: A retrospective review of patients who underwent CRS and HIPEC between 2009 and 2016 was performed to identify those with a pelvic anastomosis (colorectal, ileorectal, or coloanal anastomosis). RESULTS: The study identified 73 patients who underwent CRS and HIPEC at three different institutions between July 2009 and June of 2016. Of these patients, 32 (44%) underwent a primary anastomosis with a diverting ileostomy, whereas 41 (56%) underwent a primary anastomosis without fecal diversion. The anastomotic leak rate for the no-diversion group was 22% compared with 0% for the group with a diverting ileostomy (p < 0.01). The 90-day mortality rate for the no-diversion group was 7.1%. The hospital stay was 14.1 ± 8.0 days in the diversion group compared with 17.9 ± 12.5 days in the no-diversion group (p = 0.12). Of those patients with a diverting ileostomy, 68% (n = 22) had their bowel continuity restored, 18% of which required a laparotomy for reversal. Postoperative complications occurred for 50% of those who required a laparotomy and for 44% of those who did not require a laparotomy (p = 0.84). CONCLUSION: Diverting ileostomies in patients with a pelvic anastomosis undergoing CRS and HIPEC are associated with a significantly reduced anastomotic leak rate. Reversal of the diverting ileostomy in this patient population required a laparotomy in 18% of the cases and had an associated morbidity rate of 50%.

Volume and outcomes relationship in laparoscopic diaphragmatic hernia repair.

BACKGROUND: There is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that hospitals performing high case volume have improved outcomes compared to low-volume hospitals. MATERIALS AND METHODS: We reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 for adults with the diagnosis of diaphragmatic hernia who underwent elective laparoscopic repair of diaphragmatic Hernia and/or Nissen fundoplication. Pediatric, emergent, and open cases were excluded. Main outcome measures included logistic regression analysis of factors predictive of in-hospital mortality and outcomes according to annual hospital case volume. RESULTS: A total of 31,228 laparoscopic diaphragmatic hernia operations were analyzed. The overall in-hospital mortality was 0.14%. Risk factors for higher in-hospital mortality included renal failure (AOR: 6.26; 95% CI: 2.48-15.78; p < 0.001), age>60 years (AOR: 5.06; 95% CI: 2.38-10.76; p < 0.001), and CHF (AOR: 3.80; 95% CI: 1.39-10.38; p = 0.009) while an incremental increase in volume of 10 cases/year (AOR: 0.89; 95% CI: 0.81-0.98; p = 0.019) and diabetes (AOR: 0.34; 95% CI: 0.12-0.93; p = 0.036) decreases mortality. There was a small but significant inverse relationship between hospital case volume and mortality with a 10% reduction in adjusted odds of in-hospital mortality for every increase in 10 cases per year. Using 10 cases per year as the volume threshold, low-volume hospitals (≤10 cases/year) had almost a twofold higher mortality compared to high-volume hospitals (0.23 vs. 0.12%, respectively, p = 0.02). CONCLUSIONS: There was a small but significant inverse relationship between the hospitals' case volume and mortality in laparoscopic diaphragmatic hernia repair.

Lymph Node Positivity in Appendiceal Adenocarcinoma: Should Size Matter?

BACKGROUND: The management algorithm for appendiceal adenocarcinoma is not well defined. This study sought to determine whether tumor size or depth of invasion better correlates with the presence of lymph node metastases in appendiceal adenocarcinoma, and to compare these rates with colon adenocarcinoma. STUDY DESIGN: A retrospective review of the National Cancer Database was performed to identify patients with appendiceal or colonic adenocarcinoma from 2004 to 2013 who underwent surgical resection. Cases were categorized by tumor size and by T stage. Rates of lymph node metastases were examined as a function of size and T stage. RESULTS: A total of 3,402 appendiceal and 314,864 colonic cases were identified. For appendiceal adenocarcinoma, larger tumor size was associated with higher T stage: Pearson correlation of 0.41 (95% CI 0.408 to 0.414; p < 0.001). Lymph node metastases were present in 19.1%, 27.8%, 39.6%, 39.4%, 42.4% and 39.1% for tumor sizes <1 cm, >1 to 2 cm, >2 to 3 cm, >3 to 4 cm, >4 to 5 cm, and >5 cm, respectively. Lymph node metastases were present in 0%, 11.2%, 12.3%, 35.5%, and 40.0% for in situ, T1, T2, T3, and T4 tumors, respectively. There was no difference in the rates of lymph node metastases between appendiceal and colonic adenocarcinoma for tumor sizes <3 cm, or for in situ and T1 tumors. Rates of lymph node metastases are higher in colonic adenocarcinoma for tumor sizes >3 cm and for T2, T3, and T4 tumors (p < 0.01). CONCLUSIONS: In appendiceal adenocarcinoma, the rate of lymph node metastases is substantial, even for small tumors. Tumor size should play no role in the decision of whether to perform a hemicolectomy. Appendectomy alone does not produce an adequate lymph node sample. Right hemicolectomy should be performed for all appendiceal adenocarcinomas.

Racial Disparities in Access and Outcomes of Cholecystectomy in the United States.

Disparities in access to health care between white and minority patients are well described. We aimed to analyze the trends and outcomes of cholecystectomy based on racial classification. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy from 2009 to 2012. Patients were stratified as white or non-white. A total of 243,536 patients were analyzed: 159,901 white and 83,635 non-white. Non-white patients had significantly higher proportions of Medicaid (25% vs 9.3%), self-pay (14% vs 7.1%), and no-charge (1.8% vs 0.64%). Non-white patients had significantly higher rates of emergent admission (84% vs 78%) compared with the white patients. Multivariate analysis revealed that non-whites had a significantly longer length of stay [mean difference of 0.14 days, 95% confidence interval (CI) 0.08-0.20] and higher total hospital charges (mean difference of $6748.00, 95% CI 5994.19-7501.81) than whites, despite a lower morbidity (odds ratio 0.94, 95% CI 0.90-0.98). Use of laparoscopy and mortality were not different. These differences persisted on subgroup analysis by insurance type. These findings suggest a gap in access to and outcomes of cholecystectomy in the minority population nationwide.

Body Mass Index Significantly Impacts Outcomes of Colorectal Surgery.

There are limited data regarding the association between body mass index (BMI) and colorectal surgery outcomes. We sought to evaluate the effect of BMI on short-term surgical outcomes in colon and rectal surgery patients in the United States. The American College of Surgeons National Surgery Quality Improvement Project database was used to identify all patients who underwent colon or rectal resection from 2005 to 2013. Multivariate regression analysis was used to assess the independent effect of BMI on outcomes. A total of 206,360 patients underwent colorectal resection during the study period. Of these, 3.2 per cent of patients were underweight (BMI < 18.5), 23.8 per cent patients were normal weight (18.5 ≤ BMI < 25), 26.5 per cent were overweight (25 ≤ BMI < 30), 25.2 per cent were obese (30 ≤ BMI < 40), and 5.3 per cent were morbidly obese (BMI ≥ 40). Underweight patients had longer length of stay (confidence interval: 2.70-3.49, P < 0.001) and higher mortality (adjusted odds ratio: 1.45, P < 0.01) compared with patients with a normal BMI. Morbidly obese patients had the highest overall morbidity rate compared with normal BMI patients (adjusted odds ratio: 1.53, confidence interval: 1.42-1.64, P < 0.01). BMI is associated with outcomes in colon and rectal surgery patients. Underweight and morbidly obese patients have a significantly increased risk of postsurgical complications compared with those with normal BMI.

Analysis of Endoscopic Retrograde Cholangiopancreatography after Positive Intraoperative Cholangiogram: Is It Necessary?

The necessity of routine endoscopic retrograde cholangiopancreatography (ERCP) after positive intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy is not well defined. We aimed to examine the incidence of positive IOC among patients who undergo IOC during cholecystectomy and the rate of subsequent ERCP stone extraction. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy with IOC from 2002 to 2012. Patients were then analyzed for ERCP and stone extraction. A total of 73,508 patients who underwent cholecystectomy with IOC for a diagnosis of acute cholecystitis and found to have a bile duct stone were identified. Of these patients, 5915 underwent subsequent ERCP. In the patients that underwent subsequent ERCP, 1478 had a documented stone extraction during ERCP. The rate of stone extraction in the ERCP subset is 25 per cent, which is 2 per cent of all patients who had a positive IOC. The rate of stone extraction after positive IOC is low. Positive IOC may not warrant a routine postoperative ERCP. Our results suggest that clinical monitoring of patients with positive IOC is reasonable, as the majority of patients with a positive IOC ultimately have no stone extraction.

Future of Minimally Invasive Colorectal Surgery.

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Hand-Assisted Laparoscopic Donor Nephrectomy in Complete Situs Inversus.

Complete situs inversus is a rare congenital anomaly characterized by transposition of organs. We report a case of renal transplantation using a kidney from a living complete situs inversus donor. The recipient was a 59-year-old female with end-stage renal disease because of type 2 diabetes mellitus. The donor was the 56-year-old sister of the recipient with complete situs inversus. CT angiogram of the abdomen and pelvis showed complete situs inversus and an otherwise normal appearance of the bilateral kidneys with patent bilateral single renal arteries and longer renal vein in the right kidney. The patient was taken to the operating room for a hand-assisted laparoscopic right donor nephrectomy. The patient tolerated the procedure well and was discharged home in good condition on postoperative day 1. The recipient experienced no episodes of acute rejection or infection, with serum creatinine levels of 0.8-1.2 mg/dL. Laparoscopic donor nephrectomy in a patient with complete situs inversus remains a technically feasible operation and the presence of situs inversus should not preclude consideration for living kidney donation.

Effect of Resident Involvement on Patient Outcomes in Complex Laparoscopic Gastrointestinal Operations.

BACKGROUND: Multiple studies examining the impact of resident involvement on patient outcomes in general surgical operations have shown an associated increase in morbidity and operative time. However, these studies included basic and advanced laparoscopic and open operations. The aim of this study was to examine the impact of resident involvement on outcomes specifically in patients who underwent complex minimally invasive gastrointestinal operations. STUDY DESIGN: The American College of Surgeons NSQIP database was reviewed for patients who underwent laparoscopic colectomy and laparoscopic paraesophageal hernia and anti-reflux procedures between 2002 and 2010. Data were analyzed based on operations performed with a resident involved compared with those performed by an attending surgeon without resident involvement. Primary end points included risk-adjusted 30-day mortality, 30-day reoperation, and 30-day serious morbidity. Secondary end points were operative time, hospital length of stay, and 30-day overall morbidity. RESULTS: A total of 31,736 cases were analyzed; 63.3% of cases had a resident involved in the operation and 36.7% were performed by an attending without resident involvement. Operative time was significantly longer in cases performed with a resident (162 vs 138 minutes in attending-only cases; p < 0.01), however, there were no significant differences between groups with regard to hospital length of stay (4.5 vs 4.5 days, respectively). Compared with cases without resident involvement, risk-adjusted outcomes for cases with resident involvement showed no significant differences in 30-day serious morbidity (odds ratio = 1.03; 95% CI, 0.94-1.14; p = 1.0), 30-day mortality (odds ratio = 0.83; 95% CI, 0.60-1.15; p = 1.0), or 30-day reoperation (odds ratio = 0.93; 95% CI, 0.81-1.06; p = 1.0). CONCLUSIONS: Resident involvement in complex laparoscopic gastrointestinal procedures is associated with an increase in operative time with no impact on postoperative outcomes.